Veteran General and Financial Assistance Program Questionnaire 1.0 brought to by Commit To The Battle

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Answering the following questions allows Commit To The Battle obtain the appropriate information to provide the best resources and referrals.

What is your Name ?

What is your email address?

What is your phone number ?

What is your Branch of Service

Army

Navy

Marines

Air Force

Coast Guard

Space Force

Clear selection

What component were you in?

Active

Retired

Reserve

National Guard

Clear selection

What was your last rank?

What was your discharge status?

Honorable

General

Bad Conduct

Other:

Clear selection

Question 1 Do you need help with Mortgage payments (including escrow) and payments in arrears? (not to exceed a 6-month period per beneficiary household. (Yes to Application Fees, deposits, late fees and payments in arrears, not to exceed 6-month period per beneficiary household. *

Yes

Question 2 Do you need help with Utility payments for (Electric, Water, Gas, Garbage, Internet and cell phone service (also includes connection & re-connection fees, late fees, and payments in arrears), not to exceed a 6-month period per beneficiary household.
*

Yes

Question 3 What Utility payment do you need help with to pay?

Electric

Water

Gas

Garbage

Internet

Cell Phone

Clear selection

Question 4 Do you need Food vouchers services, not to exceed a 6-month period per beneficiary household.
*

Yes

Question 5 Do you need help with Transportation assistance including daily, weekly, monthly bus passes, train or metro rail passes, ride share & cab fare not to exceed a 3-month period.

Monthly

Train

Metro Rail

Ride Share

Cab Fare

Clear selection

Question 6 Do you need assistance with for beneficiary vehicles including fuel, repair, insurance, and loan payments not to exceed a 3-month period.

Yes

Question7 Do you need Drop in Child care services at a licensed day care facility or business.

Yes

Question 8 Do you need Adult care services at a licensed day care facility or business.
*

Yes

Question 9 Do you need help with funeral costs ( excluding costs for indigent veteran services, receptions and celebration of life) up to $6,000 to assist surviving family members who can demonstrate financial need with paying for costs of veteran funeral and interment services.
*

Yes

Question 10 Do you need help with obtaining assistive technologies to promote independent living for qualified clients including
*

Yes

Question 11 Do you need help with restorative dental-care to $2500 per beneficiary, per grant period.

Yes

Question 12 Do you need help with assistive technology services?
*

Yes

Question 13 Do you need Meal Delivery Services ?
*

Yes

Question 14 Do you need Elder Care Services?
*

Yes

Question 15 Do you need Family Support Services?
*

Yes

Question 16 Do you need Homeless Veteran Support?

Yes

Question 17 Do you need Employment Support ?
*

Yes

Question 18 Do you need Pro Bono Legal Services?
*

Yes

Question 19 Do you need Referral Services?

Yes

Question 20 Do you need Transportation Program & Services ?
*

Yes

Question 21 Do you need Veteran Small Business Support?
*

Yes

Question 22 Do you need help with Housing for Texas Heroes Program

Yes

Question 23 Do you need Veterans Mental Health Program

Yes

Question 24 Do you need Employment Support ?
*

Yes

Question 25 Do you need Peer Support Services

Yes

Question 26 Do you need help with Veterans Treatment Court Program

Yes

Question 27 Do you need help with locating a VSO ?
*

Yes

Question 28 Do you have another request not listed above? *

Yes

Other:

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