VETERANS APPLY

Please fill out the form below. Upon submission of the form and receipt of required documentation, your application will be reviewed by JAH4WW. If we have any additional questions, we will reach out via email or phone.

If you are selected to receive support, we will contact you by phone or email. Due to the limited resources available, not all applicants will receive support, and only those selected will be contacted. 

We sincerely apologize and truly thank you for the sacrifices you and your family have endured.

Prior to any applicant being approved, the following must be completed:

Step 1

Complete the Pre-qualification Form below or download, print, and submit the form offline

PREQUALIFICATIONS

Please fill out the following form as truthfully and accurately as possible.
Are you in need of a home that is handicap accessible for injuries sustained from combat?
Field is required!
Field is required!
We're truly sorry, but you do not qualify for assistance.

We truly thank you for the sacrifices that you and your family have made for our country. Unfortunately because of our limited resources at this time, we are not able to assist those that do not meet the above criteria. We will keep your information as it is our goal to be able to one day support everyone that sustained injuries while fighting for our freedom. We sincerely apologize and recommend that you continue to reach out to other organizations that may be able to assist you.

If you feel you have reached this message in error, please contact us. Thank you!

Field is required!
Field is required!
Are you declared 100% disabled by the U.S. Department of Defense (DOD) or Veterans Affairs (VA Hospital)?
Field is required!
Field is required!
We're truly sorry, but you do not qualify for assistance.

We truly thank you for the sacrifices that you and your family have made for our country. Unfortunately because of our limited resources at this time, we are not able to assist those that do not meet the above criteria. We will keep your information as it is our goal to be able to one day support everyone that sustained injuries while fighting for our freedom. We sincerely apologize and recommend that you continue to reach out to other organizations that may be able to assist you.

If you feel you have reached this message in error, please contact us. Thank you!

Field is required!
Field is required!
Did your injuries occur during OIF or OEF?
Field is required!
Field is required!
We're truly sorry, but you do not qualify for assistance.

We truly thank you for the sacrifices that you and your family have made for our country. Unfortunately because of our limited resources at this time, we are not able to assist those that do not meet the above criteria. We will keep your information as it is our goal to be able to one day support everyone that sustained injuries while fighting for our freedom. We sincerely apologize and recommend that you continue to reach out to other organizations that may be able to assist you.

If you feel you have reached this message in error, please contact us. Thank you!

Field is required!
Field is required!
What combat operation were you in when you sustained your injuries?
You must enter the name of the combat operation you were in when you sustained your injuries
You must enter the name of the combat operation you were in when you sustained your injuries
Have you been awarded the Purple Heart?
Field is required!
Field is required!
We're truly sorry, but you do not qualify for assistance.

We truly thank you for the sacrifices that you and your family have made for our country. Unfortunately because of our limited resources at this time, we are not able to assist those that do not meet the above criteria. We will keep your information as it is our goal to be able to one day support everyone that sustained injuries while fighting for our freedom. We sincerely apologize and recommend that you continue to reach out to other organizations that may be able to assist you.

If you feel you have reached this message in error, please contact us. Thank you!

Field is required!
Field is required!
Are you medically discharged for wounds resulting in the loss of a major limb, blindness or paralysis sustained in combat operations?
Field is required!
Field is required!
We're truly sorry, but you do not qualify for assistance.

We truly thank you for the sacrifices that you and your family have made for our country. Unfortunately because of our limited resources at this time, we are not able to assist those that do not meet the above criteria. We will keep your information as it is our goal to be able to one day support everyone that sustained injuries while fighting for our freedom. We sincerely apologize and recommend that you continue to reach out to other organizations that may be able to assist you.

If you feel you have reached this message in error, please contact us. Thank you!

Field is required!
Field is required!
Please mark which injuries you've sustained
To be considered for assistance, you must select which injuries you've sustained during combat operations.
To be considered for assistance, you must select which injuries you've sustained during combat operations.
Please describe your injuries in detail. Include WHERE and WHEN the injury occurred. Be as specific as possible.
Please list your injuries and how they happened. Be as specific as possible.
To be considered for assistance, you must describe your injuries in detail
To be considered for assistance, you must describe your injuries in detail

BASIC INFORMATION

First Name
Your First Name
You must enter your first name
You must enter your first name
Middle Name
Your Middle Name
You must enter your middle name
You must enter your middle name
Last Name
Your Last Name
You must enter your last name
You must enter your last name
Address
Your Address
Field is required!
Field is required!
City
City
You must enter the name of the city that you currently live in.
You must enter the name of the city that you currently live in.
State
  • - select a option -
  • AL
  • AK
  • AZ
  • AR
  • CA
  • CO
  • CT
  • DE
  • DC
  • FL
  • GA
  • HI
  • ID
  • IL
  • IN
  • IA
  • KS
  • KY
  • LA
  • ME
  • MD
  • MA
  • MI
  • MN
  • MS
  • MO
  • MT
  • NE
  • NV
  • NH
  • NJ
  • NM
  • NY
  • NC
  • ND
  • OH
  • OK
  • OR
  • PA
  • RI
  • SC
  • SD
  • TN
  • TX
  • UT
  • VT
  • VA
  • WA
  • WV
  • WI
  • WY
- select a option -
Please select your current state
Please select your current state
Zip
Zipcode
You must enter your current zip code.
You must enter your current zip code.
Phone Number
Your Phone number
You must enter your phone number
You must enter your phone number
Email Address
Your Email Address
You must enter your email address
You must enter your email address
Military Branch
  • - select a option -
  • Army
  • Navy
  • Air Force
  • Marine Corps
  • Coast Guard
- select a option -
You must select in which military branch you served when you sustained your injury
You must select in which military branch you served when you sustained your injury
What is Your Current Rank?
Your current rank
You must enter your current rank
You must enter your current rank
Marital Status
You must select your marital status
You must select your marital status
Number of Dependents
  • - select a option -
  • Only yourself
  • 1
  • 2
  • 3
  • 4
  • 5 or more
- select a option -
You must select how many dependents you have
You must select how many dependents you have
Upon discharge did you receive DD Form 214 (Military Dishcarge) with a good RE Code (Re-enlistment Code)?
  • - select a option -
  • Yes
  • No
- select a option -
You must select if you received your DD Form 214
You must select if you received your DD Form 214

FINANCIAL INFORMATION

Have you applied for any federal or private assistance programs in the past?
This field is required
This field is required
Please Explain Your Benefits
Please explain in as much detail as possible
Field is required!
Field is required!
Please explain any personal or family circumstances affecting your need for financial assistance.
Please explain in as much detail as possible
Field is required!
Field is required!

BACKGROUND INFORMATION

Have you ever been convicted of a felony?
This is a required field
This is a required field
Please explain, including the offense and the state in which it occurred.
Please explain in as much detail as possible
Field is required!
Field is required!

CURRENT HOUSING

Do you currently own a home?
This is a required field
This is a required field
How is your home not suitable for your current medical conditions?
Please explain in as much detail as possible
Field is required!
Field is required!
Are you eligible for either the Specially Adapted Housing (SAH) or Special Housing Adaption (SHA) program from the VA?
This is a required field
This is a required field
Have you ever received any grants from this program?
This is a required field
This is a required field
Please describe how being selected for a handicap accessible home would affect your life. This is your opportunity to let us know why we should select you and how this would positively make an impact in your life.
Please explain in as much detail as possible
You must fill out this field
You must fill out this field
Where would you like to live/have your home build if selected?
Please explain in as much detail as possible
You must fill out this field
You must fill out this field
Please describe how being selected for a handicap accessible home would affect your life. This is your opportunity to let us know why we should select you and how this would positively make an impact in your life.
Please explain in as much detail as possible
You must fill out this field
You must fill out this field

REFERENCES

To be considered for assistance, you must provide two references who are not related to you.
Field is required!
Field is required!
Reference #1 Name
Full Name
You must enter a non-related reference
You must enter a non-related reference
Reference #1 Relationship
Relationship to the applicant
This is a required field
This is a required field
Reference #1 Phone
123-456-7890
You must enter a phone number for Reference #1
You must enter a phone number for Reference #1
Reference #2 Name
Full Name
You must enter a non-related reference
You must enter a non-related reference
Reference #2 Relationship
Relationship to the applicant
This is a required field
This is a required field
Reference #2 Phone
123-456-7890
You must enter a phone number for Reference #1
You must enter a phone number for Reference #1
Submit

Step 2

The following must be submitted

  • Last two pay stubs
  • Most recent tax return and W-2 Form
  • Last two months bank statements
  • Copy of your purple heart
  • DD Form 214
  • Letter of recommendation from your VA case worker or your previous commanding officer

Please Submit to:
9845 E Bell Road; Suite 130 
Scottsdale, AZ 85260

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