Assistance for Heroes

Applying for Assistance

After completing the application below you will need to attach a .pdf file (scanned image) or .jpg file (picture image) of the following documents:

Your DD-214 Form
Your most recent (last year or current year) Signed, Federal 1040 Tax Return.
Proof of current healthcare insurance coverage including: name of insured, dates of coverage, and proof of payment OR copies of paid receipts for out-of-pocket healthcare expenses that you have paid for this year or last year.

These documents will be used for verification purposes and must accompany your application in order for your application to be reviewed.

Fields marked with an asterisk (*) are required.

Contact Information

Your First Name*

Middle Name/Initial

Your Last Name*

Primary Phone Number*

Email Address*

Street Address*

Street Address Line 2

City*

State*

Zip Code*

Year of Birth*

Last 4 digits of your Social Security Number*

How did you hear about us?*

Service Information

I was Generally/Honorably Discharged from the*
US Air ForceUS ArmyUS Coast GuardUS MarinesUS Navy

Military Service Dates (enter date ranges below)

Active Duty*

Reserve

Discharge Rank*

I received the following recognition / commendations while serving

Income and Healthcare Expense Information

My current health insurance provider is (enter name of insurer or NONE)*
Insurer issuing Statement of Coverage)

My household's Adjusted Gross Income as reported on my most recent Federal Tax Return was*

My current household size (dependents) as reported on my most recent Federal Tax Return is*
Individual VeteranHousehold of 2Household of 3Household of 4Household of 5Household of 6

Optional Personal Information

The following information WILL NOT be used in any way to determine eligibility for a Bridges For Heroes grant. This information is collected to assist Bridges For Heroes in obtaining additional funding and is always used in a collective/total population fashion and is not used to identify any individual.

Race*?
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite

Gender*
MaleFemale

Required Documents

Please upload your DD-214 Form* (PDF or JPG only, 4mb max file size):

Please upload proof of current healthcare insurance coverage including name of insured, dates of coverage, and proof of payment OR copies of paid receipts for out-of-pocket healthcare expenses that you have paid for this year (in $150 increments, up to $600 per year).* (PDF or JPG only, 4mb max file size):

Please upload the first two pages of your most recent Federal 1040 Tax Return.* (PDF or JPG only, 4mb max file size):

Optional

Comments or Questions