Rallye For Veterans · Relief Form

Contact Information

Name

First Name

Last Name

Email

Verify Email

Phone

*

Race/Ethnicity

*

Age

*

Gender

*

Household Income

*

Employment Status

*

Full Time

Part Time

Retired

Unemployed

Type of Assistance

*

Branch of Service

*

Mortgage Information

More information about your mortgage situation

Please select all that apply

I am at risk of foreclosure

I am at risk of becoming homeless

I currently support others in my home

How far behind on mortgage payment?

*

Please add the full amount due on your mortgage

What is your current mortgage monthly payment?

*

Please add the full amount due each month

Medical Assistance Information

More information about your medical bills

Please select all that apply

Are you at risk of being sent to medical collection?

Are you receiving medical assistance from any other entity?

Do you currently have health insurance? IE Tricare for life, Medicare, etc.

How much do you owe in medical bills?

*

Please enter the full amount due on your medical bills

More information

*

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.

Address

*

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.

Identification

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

Proof of Service

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