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First Name
Last Name
Email
Phone Number
Date Of Birth
Gender
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Male
Female
Marital Status
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Single
Married
Divorced
Widowed
Other
Is Your Spouse Service-Connected?
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Yes
No
Branch Of Military Or First Responder Service
What Years Did You Serve?
Veteran ID Number (DD-214 or ID.me)
Number Of Dependents?
Please List Ages, Gender, And Birthdates Of Dependents
Street Address
City
State
Zip Code
Personal Advocate Or Organization (Non-Family)
Closest Emergency Contact (Name & Phone)
What Obstacle Is Currently Holding You Back?
Have You Had Thoughts Of Hurting Yourself Or Others?
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Yes
No
Are You Employed?
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Yes
No
Do You Have A Service-Related Disability Rating?
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Yes
No
Are you currently or have you recently received assistance from other organizations
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Yes
No
Have You Ever Supported A Nonprofit Organization?
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Yes
No
Are you Dealing With A Diagnosed Physical Or Mental Condition That Affects Your Quality Of Life?
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Yes
No
Would You Allow Us To Receive Relevant Information From your HealthCare Provider Or Care Institution For Vetting Purposes?
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Yes
No
Please List Any Other Hardships You're Currently Facing?
Are you Facing Any Pending Criminal Charges Or have You Been Charged In The Past?
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Yes
No
What Have You Already Done To Help Yourself?
What Is Your Timeline Or Deadline For Your Request?
What Is Your Very Specific Request From THE PEOPLE'S PATRIOT PROJECT?
In Your Estimation, What Is The Monetary Value Of Your Request In Dollars?
Is There Anything Else You'd Like To Share To Help Us Better Understand Your Needs?
how did you hear about THE PEOPLE’S PATRIOT PROJECT or who referred you to us
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