Veteran Assistance Request Form

Step 1: Before you begin, it’s important to state that while we want to help everyone, we are only able to provide assistance to homeless, at-risk, or low-income veterans in the Central Florida Area. If you are a non-veteran in need of assistance in Brevard County, we recommend you dial 211 or visit www.211brevard.org to be connected to dozens of agencies that assist clients in your particular situation.

Step 2: Please complete the form below to the best of your ability, as the information you enter will help us develop a personalized case management plan for your current situation. Required questions and fields will be indicated by a red *, all others are optional, but the more information you provide the quicker we can assist you. All data input into this form is secure and will not be shared without your permission with anyone. (click here to review privacy policy)

Toward the end of the form, you have the option to upload documents related to your case such as:

1. Housing and/or Utility payment assistance supporting documentation (i.e. rent/utility bill/deposit information)
   1. If you are seeking assistance for a Florida Power and Light (FPL) bill, please complete this form
2. Proof of Identification and Veteran Status (i.e. DD214, VA Card, Military ID, State ID, etc…)
   1. In order to work directly with the Department of Veteran Affairs on your case, please fill out this form and upload in this section.
3. Proof of Income (i.e. social security/VA determination letter, food stamp letter, pay stub, etc…)

When uploading these documents they can be in whatever format you want, even a photo, but its helpful to have this before you start the application. The most important thing is that the application is completed, so if you are having trouble completing the application and uploading documents, just submit it and we will work on the rest when we contact you back.