Apply for Home Modifications Program Step 1 of 12 8% I have read and understand the Program Details* Yes, I have read and I understand the requirements Name* First Middle Last Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number*Current Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Mobile Phone*Email* Marital Status*SingleMarriedWidowedNumber of Dependents*0123456789101112131415Age of Dependants*Branch of ServiceArmyNavyAir ForceMarinesCoast GuardRank / Grade / Title*Are you currently active duty?* Yes No Have you been honorably discharged from the U.S. armed forces?* Yes No Discharge Date MM slash DD slash YYYY Disability Rating*100%90%80%70%60%50%OtherDescription of Injuries*Case Worker NameCase Worker PhoneCase Worker Email Why did you join the military? Where did you join? Dates of Service?*Please provide as much detail as possible so we may better understand your specific experiences.When were your injuries sustained?* MM slash DD slash YYYY Are you rated as having "permanent and total service connected" disability?* Yes No Have you received an approval letter for Specially Adapted Housing (SAH)?* Yes No How did you hear about Building Homes For Heroes?*Please list all awards and/or military decorations received by the applicant.*Do you require a wheelchair? If so, what percent of time?*Have you suffered a traumatic brain injury (TBI)?* Yes No Have you been diagnosed with post traumatic stress disorder (PTSD)?* Yes No Do you have vision loss?* Yes No If you have vision loss, please describe the severity of your vision loss.Do you have hearing loss?* Yes No If you have hearing loss, please describe the severity of your hearing loss.Please provide a detailed account of the day your injuries were sustained.* Provide an overview of exactly what your needs in a home are? (example: grab bars in the shower)*Please provide pictures of existing area you wish to be modified Drop files here or Select files Max. file size: 10 MB. Current residence*Own a homeRentLive with familyOtherOther, please explainHave you been charged or convicted of a crime? Answering "yes" does not automatically disqualify you.* Yes No If yes, please explain. Answering "yes" does not automatically disqualify you. Have you ever filed for bankruptcy or had a home foreclosed?* Yes No If yes, please explainPlease list all sources and amounts of household income.*(If selected for one of our homes, you will be responsible for all costs associated with owning the home; taxes, utilities, HOA fees (if applicable), etc.)Please list all of your monthly expenses and liabilities.*(If selected for a home, you will be assigned a financial advisor that will ask you to verify this question. Please be detailed and include ALL debt)Please tell us what your plans are for the future?*Please tell us what receiving a home modification would mean to you and your family.*Required DocumentsDD Form 214*Max. file size: 5 MB.PDF preferredCopy of Deed*Max. file size: 10 MB.PDF PreferredCopy of MortgageMax. file size: 10 MB.PDF Preferred Benefit Summary Letter*Max. file size: 5 MB.PDF preferredMedical Records (Additional)Max. file size: 5 MB. Authorization to Release Information Waiver*Max. file size: 5 MB.PDF preferredPhoto Authorization Waiver*Max. file size: 5 MB.PDF preferred Letter of Recommendation #1*Max. file size: 5 MB.PDF preferredLetter of Recommendation #2*Max. file size: 5 MB.PDF preferred Bid / Estimate*Max. file size: 5 MB.PDF preferredBid / Estimate*Max. file size: 5 MB.PDF preferredBid / EstimateMax. file size: 5 MB.PDF preferred PhotographsIn the section below, please provide photos to help tell your story (i.e. before injury, during recovery, after recovery, family photos, military photos, etc.)Photo #1*Max. file size: 5 MB.Please be sure to submit a high resolution photo. Photo #2*Max. file size: 5 MB.Please be sure to submit a high resolution photo. Photo #3*Max. file size: 5 MB.Please be sure to submit a high resolution photo. Photo #4Max. file size: 5 MB.Please be sure to submit a high resolution photo. Photo #5Max. file size: 5 MB.Please be sure to submit a high resolution photo. Photo #6Max. file size: 5 MB.Please be sure to submit a high resolution photo. By typing my name I am signing the agreement below*I certify that all statements made herein and on the enclosed application are true and correct to the best of my knowledge. I authorize investigation of all statements herein recorded. I release from liability all persons and organizations reporting information required by this application. I understand that if selected as a home recipient, any false, incomplete, or omitted information on this application will be considered sufficient dismissal from the program and may result in the loss of any gifted property as well as any civil remedies available at law.EmailThis field is for validation purposes and should be left unchanged.