{fullName66}

Thank You for your Service!
The next questions are of a personal nature and will require specific knowledge of the Veteran's background. It is recommended that you fill in this application in his/her presence or on the phone in real time - This will save you a lot of time and will provide us with accurate information.

NOTE: You will be asked for scanned documents - If you do not have them, do not proceed until you have aqcuired them as the application will not be processed. Thank you -
Please answer the following questions in the Veteran's name
Have you been discharged from your military service?*

YesNo
Have you filed a claim with the Veterans Administration (VA)?*

YesNo
Have you suffered an injury in the Line of Duty?*

YesNo
Click on NEXT to proceed to the next part of the questionaire.

OK - now this step is important

Please upload a copy of the documents requested below - we can not process your application without them. *NOTE: For your security, make a copy of the documents and WHITE OUT your Social Security Number before you send them using the Internet. We don't want it. (If you have previously submitted these documents we do not need them again. However, the system requires that you upload something in order to move onto the next step).
Upload your DD214*

Upload a File
pdf, jpg, jpeg, png Cancelof
Upload an official VA document clearly showing your Service Related injury/disability

Upload a File
pdf, jpg, jpeg, png Cancelof
Upload Military ID Card*

Upload a File
pdf, jpg, jpeg, png Cancelof
Upload your "Position Documentation"*

Upload a File
pdf, jpg, jpeg, png Cancelof
Additional documents

Upload a File
*Optional Cancelof
After you have chosen the files, click on NEXT to proceed to the next part of the questionaire.

General Information

Please provide us with the CORRECT information - this is essential so that we can get a hold of you as soon as possible! *Please note that all of your information is on a secured server, and will not be passed on to any external party beyond the Independence Fund.
Applicant's Name*
*Name of person filling this application
Veteran's Full Name*

First NameLast Name
Rank*
Example: Private, Sgt Major, etc...
Branch*
Example: ARMY, NAVY, MARINES, etc...
Unit*
Example: 101st Airborn Infantry
Requested Assistance*
How did you hear about The Independence Fund?*
Contact Information
E-mail*

Confirmation EmailYou will receive emails from us ONLY - No Spam
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Injury Related Information
Date of Injury

MonthDayYear
Summary of Current Medical Condition*
% of Disability Issued by the VA
***If you would like to inform us about anything urgent and/or specific, you can do so by sending us an email to: IndependenceFund@gmail.com - We will reply as soon as possible!
By checking this box I agree to waive The Independence Fund of all liability pertaining to the mobility device that I select.
Thats it - now just click Submit!