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If you are seeking assistance, please fill out the form below and some will contact you as soon as possible. 

As part of the verification process, please be prepared to submit a copy of one of the following documents:

  • DD214 (Member 4 or Service 2)
  • VA ratings decision (showing dates of service and VA ratings)
  • Enlisted Record Brief (ERB) or Officer Record Brief (ORB)
  • Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB) narrative letter
  • Current unit orders (if you are on active duty) to a Warrior Transition Unit (WTU) or Warrior Transition Battalion (WTB)
  • Line of Duty (LOD) documentation – form and memo
  • Purple Heart Orders or Citation


Other official documents verifying eligibility will be considered on a case-by-case basis. 


Basic Information
Current Status *
Name *
Name
Date of Birth *
Date of Birth
Phone
Phone
Address
Address
Service Information
Service Start Date *
Service Start Date
Service End Date *
Service End Date
Enter anticipated discharge date if still in service.