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Contact Information

First Name
Last Name


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Mortgage Information
Please select all that apply
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Please add the full amount due on your mortgage
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Please add the full amount due each month
Medical Assistance Information
Please select all that apply
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Please enter the full amount due on your medical bills
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At Rallye for Vets it’s important to us that we serve our veterans who have served our country. Specifically, those who have fallen on hard times and are in need. Please write a short statement why you believe you should be selected to receive relief funds. While we would like to help all our veterans who are in need, we are limited by the funds donated.
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country

Note: Please know that if you are selected to receive assistance from Rallye for Vets, we will require proof of service. IE a D214, VA ID card, Retiree card, ECT. These items will be verified in a secure manner and will not be kept on file. Additionally, we will also require the veteran to produce a medical bill or mortgage statement in order to provide assistance.


Copy of Driver’s License or other form of Government issued ID

DD214 (preferred) or Proof of Service letter or discharge papers