USA Cares Assistance Request Form...

Information

* Service Member's First Name:

* Last Name:

* Marital Status & # of Children:

* Home of Record:

* Branch:

Air Force
Army
Coast Guard
Marines
Navy

* Your Status:

Spouse/Family Member
Active Military
Demobilized
Mobilized
Injured/Med Hold
National Guard/Reserve

* Unit Assigned:

* Unit Phone Number:

* Unit Contact Person:

Contact Information (Requester)

* First Name:

* Last Name:

* Relationship To Service Member:

* Phone Number:

* Address:

* City:

* State:

* ZIP Code:

Email Address:

* Other Agencies Contacted:

USA Cares provides assitance with quality of life items (food, shelter, primary vehicle repairs and payments.)

*Amount of Request:

* Summary of Need and
Cause of Hardship:

*Verification: This information is true to the best of my knowledge:

*How Did You Hear About Us?:

*Full Name of Requester:

*Required Field!

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