Survey - Home Award Application - Homes For Our Troops

1.

Contact Information

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

Country:

*

Phone Number: Required

Employer:

*

Date of Birth: Required

Date of Birth:

If you respond and have not already registered, you will receive periodic updates and communications from Homes For Our Troops.

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Please enter a user name and password for logging in when you return. You can use this password to update your information or receive personalized content.

*	User Name: Required	5 to 60 characters
*	Password: Required	5 to 20 characters
*	Repeat Password: Required

*2.

Question - Required - Branch of Service
Please make between 1 and 3 selections from the choices below.

	Army
	Marines
	Navy
	Air Force
	Coast Guard

*3.

Question - Required - Conflict where you were injured:
Please make between 1 and 3 selections from the choices below.

	Operation Iraqi Freedom
	Operation Enduring Freedom
	Operation New Dawn
	Other

*4.

Question - Required - Current Military Status: Please tell us the date you were medically retired or the expected date you will be medically retired from the military.

*5.

Question - Required - Discharge Status:

*6.

Question - Required - Are you medically retired?

7.

Question - Not Required - Rank upon discharge:

*8.

Question - Required - Military unit you (or spouse) were assigned to when injured (e.g. 168 Infantry):

*9.

Question - Required - Where is the unit based? (ie. Fort Bragg, Camp Pendleton, etc)

*10.

Question - Required - Where and when did the injury occur? (Date, City, Country)

*11.

Question - Required - Were you awarded the Purple Heart Medal?

12.

Question - Not Required - OIF/OEF/OND deployment dates: List deployments in order [Deployment #1 (date to date & operation), Deployment #2 (date to date & operation), etc.]

(Maximum response 255 chars, approx. 5 rows of text)

13.

Question - Not Required - Please briefly describe injuries, date and how sustained:

(Maximum response 255 chars, approx. 5 rows of text)

*14.

Question - Required - Did you or your spouse receive a VA disability rating due to injuries? If yes, what is the VA Disability rating percentage?

*15.

Question - Required - Marital Status:
Please make between 1 and 3 selections from the choices below.

	Married
	Single
	Widowed
	Divorced
	Separated
	Engaged

16.

Question - Not Required - Name of Spouse

*17.

Question - Required - Please list all your children and step-children who will reside with you full-time: Include: Name, Date of Birth, Male or Female

18.

Question - Not Required - Please list any other family members (spouse, parents, sibling, caretaker, fiancee, etc.) who will reside full-time in your home.

*19.

Question - Required - How many bedrooms do you need in your home?
Please make between 1 and 3 selections from the choices below.

	1 or more
	2 or more
	3 or more
	4 or more

20.

Question - Not Required - Please describe your current living arrangements, including any adverse aspects of the situation: (base housing, rent, not enough bedrooms, living with parents etc)

(Maximum response 255 chars, approx. 5 rows of text)

21.

Question - Not Required - Do you qualify for the VA Specially Adaptable Housing Grant (VA SAH Grant)?

*22.

Question - Required - What style home will best fit your needs:
Please make between 1 and 3 selections from the choices below.

	Single-story (Ranch style)
	Multi-story (Split level, Basement, Two-story etc)
	We are flexible

*23.

Question - Required - When would you be prepared to move into a home:
Please make between 1 and 3 selections from the choices below.

	Immediately
	1-3 months
	3-6 months
	6-9 months
	9-12 months
	1 year or more

*24.

Question - Required - In what geographical location(s) do you prefer to reside? Please list first, second, and third choices. (MUST LIST City, State, County in order to be considered)

*25.

Question - Required - What radius around this area are you willing to consider? (**Flexibility is preferred as the location depends on the availability of homes from the banks)
Please make between 1 and 2 selections from the choices below.

	0 miles
	0-10 miles
	0-20 miles
	0-30 miles
	0-40 miles
	flexible

26.

Question - Not Required - Are there any other locations you would be interested in? If yes, please list: (City, State, County)

27.

Question - Not Required - Is there any additional information you would like to provide regarding your desired location?

*28.

Question - Required - Are you currently employed?
Please make 1 selection from the choices below.

	Yes
	No

*29.

Question - Required - Annual income from employment (gross):

*30.

Question - Required - Employer Information: Please provide name, point of contact, phone number, and employer's address.

*31.

Question - Required - Do you receive VA Disability Compensation? If yes, please list monthly amount.

*32.

Question - Required - Do you receive Combat Related Special Compensation (CRSC)? If yes, please list monthly amount.

*33.

Question - Required - Do you (or your spouse and/or children) receive Social Security? If yes, please list monthly amount.

*34.

Question - Required - Have you received SGLI or TSGLI? If yes, list date paid and amount received.

*35.

Question - Required - Do you have a Trust Fund? If yes, please list original amount and amount remaining.

*36.

Question - Required - Are you receiving Lottery income? If yes, please list annual amount received.

*37.

Question - Required - Are you receiving Annuity income? If yes, please list annual income from annuity.

*38.

Question - Required - Are you, your spouse or children receiving any other forms of household income that you have not disclosed on this application such as: rental income, spouse's income, VA Caregiver Allowance, GI Bill Housing Allowance, stipend, etc? If yes, please list sources and monthly income from each source.

*39.

Question - Required - Do you or your spouse have a mortgage, or own a home, land or any other type of real estate? If yes, please list type, address, purchase date, purchase price, amount you still owe, and current value.

*40.

Question - Required - Please list all vehicles you and/or spouse currently own. (Year, Make, Model)

*41.

Question - Required - Stocks/Bonds/CD/Banks: Please list total value of all stocks, bonds,CD's, retirement & bank accounts currently held by you and/or spouse. (bank/company name, Account type: 401K, IRA, TSP, etc & balance)

*42.

Question - Required - Did you or your spouse receive a military bonus or severance pay during the last three years? If Yes, list amount & date paid.

Monthly Financial Responsibilities

*43.

Question - Required - Monthly Rent/Mortgage payment:

*44.

Question - Required - Monthly car payment(s):

*45.

Question - Required - Monthly electric payment:

*46.

Question - Required - Monthly gas/oil payment:

*47.

Question - Required - Monthly phone, cable, & internet payments:

*48.

Question - Required - Monthly cell phone payment:

*49.

Question - Required - Monthly grocery/food expenses:

*50.

Question - Required - Monthly clothing expenses:

*51.

Question - Required - Monthly court-ordered Child Support payments:

*52.

Question - Required - Monthly Health Insurance payment:

*53.

Question - Required - Monthly Life Insurance payment:

*54.

Question - Required - Monthly property insurance payment:

*55.

Question - Required - Monthly Auto Insurance payment:

*56.

Question - Required - Monthly Educational expenses:

*57.

Question - Required - Monthly child care payments:

*58.

Question - Required - Monthly credit card payment(s):

*59.

Question - Required - Other monthly payments (list type & amount):

Background Information

*60.

Question - Required - Have you or your spouse had any property foreclosed the last 7 years?

*61.

Question - Required - Have you or your spouse declared bankruptcy in the last 7 years?

*62.

Question - Required - Did you or your spouse have any debt due to a court decision against you? If yes, please explain.

*63.

Question - Required - Have you or your spouse ever been arrested or charged with a crime?

*64.

Question - Required - Have you or your spouse ever been convicted of a crime or a military court martial?

*65.

Question - Required - Are you or your spouse currently involved in a lawsuit?

*66.

Question - Required - Are you currently involved in a divorce proceeding?

*67.

Question - Required - Are there documented cases of involvement in spousal or child abuse for you or your spouse?

*68.

Question - Required - Are you or your spouse registered, or is either one of you required to register, as a sex offender?

*69.

Question - Required - Do you or your spouse currently receive alimony or child support? What is the monthly amount?

*70.

Question - Required - Are you presently working with and/or have you benefitted from ANY non-profit organization or community fundraiser since your injury? If yes, please list the organization's name, benefit received (include: financial assistance, vehicle donation, home modifications etc.) and value of donation.