Coalition to Salute America's Heroes

Providing Emergency Financial Aid and Other Services to Veterans Severely Wounded in Iraq and Afghanistan

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Program Application for Emergency Financial Aid

You sacrificed. We are here to help.

The mission of the Coalition to Salute America's Heroes is to assist veterans who have been severely injured while serving in Operation Iraqi Freedom and Operation Enduring Freedom, and their families, and to encourage other organizations and the general public to participate in this effort.

To be considered for Emergency Financial Aid, applicants must meet the following minimum eligibility requirements:

An injury sustained during combat in Operation Iraqi Freedom or Operation Enduring Freedom, or in support of those operations in a hostile environment;
A disability rating assigned by the Department of Defense or the Department of Veterans Affairs of 30 percent or greater from a single, sustained injury;
Currently experiencing severe financial hardship;
Completion of a Coalition to Salute America's Heroes aid application and timely submission of supporting documentation as requested; and
Completion of a phone interview with a Coalition to Salute America's Heroes case manager.

Please note that while the Coalition wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified veterans. Therefore, we can only respond to requests based on our available resources.

Please also note that the Coalition sincerely respects your privacy. The information you provide below will be kept confidential and not shared with any third party.

indicates required field.

General Information

First Name

Middle Name

Last Name

Email Address

Permanent Address

Street Address

City

State

Zip Code

Phone

(ie.: xxx-xxx-xxxx)

Cell Number

(ie.: xxx-xxx-xxxx)

Mailing Address (If different from permanent address)

Street Address

City

State

Zip Code

Gender

Birth Date

Marital Status

Spouse's Name

Do you have children?

Yes No

For each child, please indicate the following:

1. Biological, Step Children, or Other (specify other)
2. Male or Female
3. Age

Education Status

Are you a student?

Yes No

If so, where?

Student Type

Are you receiving school aid through:

GI Bill

Yes No

Voc-Rehab

Yes No

Are you receiving a stipend from government educational programs?

Yes No

Amount per Month?

How did you hear about the Coalition to Salute America's Heroes?

Please enter code here if applicable

May we contact you for more information?

Yes No

NOTICE

The completion of this application does not guarantee the awarding of emergency financial assistance from the Coalition to Salute America's Heroes.

The applicant agrees that the name appearing in the signature block below is the true and legal name of the applicant and serves as an electronic "signature" to this application. Further, the applicant attests to the fact that the information contained herein is true and accurate to the best of the applicant's knowledge.

Full name

Coalition to Salute America's Heroes
552 Fort Evans Road, Suite 300
Leesburg, VA 20176
703-291-4605
www.saluteheroes.org