Application of Interest

The primary qualification to be considered as a candidate for the program is that you have been honorably discharged with a whole person impairment as described by the AMA Guidelines. Answers to these questions will help us identify alternative funding sources.
* required field

First Name: *

John

Last Name: *

Doe

Address: *

1234 Home Ave.

Email:

john@test.com

Phone: *

555-555-5555

Additional Contact Info:

Please enter additional contact info if needed

1.) Is your status as a veteran established as serving on active duty during "Wartime Service?": *

yes

2.) Are you rated as having "permanent and total service connected" disability? : *

yes

3.) Do you meet the requirements for the Specially Adapted Housing (SAH) Grant from the Veterans Administration?: *

yes

Requirements for the SAH Grant are: a. Loss or loss of use of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes or a wheelchair. b. Loss or loss of use of both upper extremities at or above the elbow. c. Blindness in both eyes, having only light perception, plus loss or loss of use of one lower extremity. d. Loss, or loss of use, of one lower extremity together with (a) residuals of organic disease or injury, or (b) the loss or loss of use of one upper extremity which so affects the functions of balance or propulsion as to preclude locomotion without the use of braces, canes, crutches or a wheelchair.

4.) Were the wounds and/or injuries that qualify you for the SAH Grant received in a combat theater of operations, after September 11, 2001?: *

yes