Application for Services - Heidrea For Heroes

Veteran Support Services Application Form

All applicants need to provide answers to the following questions and provide a copy of their DD214 form, MA ID, & 3 months current bank statements. If you are a widow of a veteran provide a copy of your marriage certificate in addition to the material listed above. Questions marked with an asterisk are mandatory; others are optional.

I am a widow of a Veteran:

Name*

Date of Birth*

Address*

City*

State*

Zip*

Spouse Name (if applicable)

Number of Dependents(if applicable)

Phone*

Email*

How Did You Hear About Us?*

What is your ethnicity?

Military Branch*

Military Job Title*

Years of Service (Date Range)*

Highest Rank*

Please list any oversees military tours you participated in, and describe your role/experience.

Did you suffer any injuries from active duty? Please describe (optional).

Are you Currently Employed?

If yes, list employer:

Please describe the type of support you are requesting; please provide as many specifics as possible to help us in evaluating your request (i.e. adaptive housing or transportation modifications, family support, specialized mobility equipment, etc.):

Provide a description of how/why this support will improve or enhance your daily needs:

(This is optional, and will not affect the approval of this application).
If H4H fulfills this request, do you authorize us to share your name and story in future H4H materials or website content?
May we use your picture?

By submitting this application for support, I authorize the staff at Heidrea for Heroes, Inc. to discuss my request, if needed, with local Veteran Service Officer(s), the Department of Veteran Affairs, the Department of Veterans Services, and similar veteran service organizations and to review my client record through these agencies. The purpose of such review is to fully evaluate the request to determine if we can assist the client in any way.

Please submit all additional documents needed by one of the following:
Fax to: 774.773.3955
Scan & Email to: info@heidrea4heroes.org
Mail to: Heidrea for Heroes
10 Cordage Park Circle, Suite 224
Plymouth, MA 02360