Please complete this form and submit your documents to us by uploading them with this application, via email or via fax at (703) 580-6339. Upon receipt, we will get back to you within five business days. We do not offer financial assistance. Caregiver InformationName of Caregiver First Last Caregiver Date of Birth* MM slash DD slash YYYY Caregiver Email Enter Email Confirm Email Caregiver Mobile PhoneCaregiver Preferred PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do You Live With The Veteran Yes No Caregiver Relationship to VeteranHusbandWifeMotherFatherGrandparentSonDaughterSiblingMother-in-LawFather-in-LawOtherCaregiver EducationLess Than High SchoolHigh School Diploma or EquivalentSome College, No DegreeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctoral of Professional DegreeCaregiver Employment StatusUnemployedPart-time EmployeeFull-time EmployeeRetiredUnable to work due to disabilitySelf-EmployedStage of PCAFC evaluation/re-evaluation*(Choose one.)NoneImmediate pending evaluation/re-evaluation (I have a date for the assessment in hand.)Pre-re-evaluation (I know it's coming, but I do not have a date in hand.)Denial/appeal process (I have a denial in hand and would like to do a VHA CLINICAL APPEAL.)Date of Denial MM slash DD slash YYYY Have you done a VHA Appeal? Yes No Date of VHA Appeal MM slash DD slash YYYY Reason for Contacting UsAdvocacy with DoDAdvocacy with VAAdvocacy with VA Caregiver Support ProgramOther Advocacy (*We no longer offer financial assistance.)If Other Advocacy, Please SpecifyFamily InformationOthers in HouseholdNameRelationshipDate of Birth Enter Name, Relationship, and Date of Birth of each additional member of your household. Click the plus sign to add another line.Caregiver ProgramEnrolled in the VA Caregiver ProgramYesNoIf Yes, What Tier?N/A321Estimated Number of Hours/Week of Caregiving You Provide for the VeteranVeteran InformationName of Veteran First Last Veteran Date of Birth MM slash DD slash YYYY Veteran Email Veteran PhoneVeteran EducationLess than High SchoolHigh School Diploma or EquivalentSome College, No DegreeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctoral or Professional DegreeVeteran EmploymentPart-time employeeFull-time employeeRetiredUnable to work due to disabilityUnemployedSelf-employedPRNOtherIf Other, Please ExplainMilitary RankE-01E-02E-03E-04E-05E-06E-07E-08E-09O-01O-02O-03O-04O-05O-06O-07O-08O-09W-01W-02W-03W-04W-05Branch of Service Air Force Air Force Reserve Air National Guard Army Army Reserve Army National Guard Coast Guard Coast Guard Reserve Marine Corps Marine Corps Reserve Navy Navy Reserve Dicharge Date MM slash DD slash YYYY Service StatusActiveReserveDischargedNational GuardPermanent Disability Retired List (PDRL)Temporary Disability Retired List (TDRL)Type of DischargeHonorableGeneral Under Honorable ConditionsAdministrativeGeneral Under Other Than Honorable ConditionsBad ConductPurple HeartYesNoPendingTotal Number of DeploymentsLocation of Last DeploymentIraqAfghanistanOtherIf Other, Please ExplainStart Date of Last Deployment MM slash DD slash YYYY Return Date of Last Deployment MM slash DD slash YYYY Nature of Wound, Illness, or InjuryWounded in CombatInjured Non-CombatIllnessTraining AccidentDate of Wound, Illness, or Injury MM slash DD slash YYYY Location of InjuryIraqAfghanistanNon-Military Duty LocationOther Military Duty LocationPlease Briefly Describe Injuries and How they OccurredVA/DoD Benefits Utilized Clothing Allowance GI Bill Vocational Rehabilitation Home Modification Grant Vehicle Grant TSGLI Other If Other, Please ExplainVA/DoD/Nonprofit/Case Manager/Point of ContactNameTitleTelephoneEmail Enter Name, Title, Telephone, and Email of your VA/DoD/Nonprofit/Case Manager/Point of Contact. Click the plus sign to add another line.Please name any organization you have received financial assistance from, now or in the past. (Enter None if not applicable.)How Did You Hear About Us?Upload Documents Drop files here or Select files Accepted file types: pdf, gif, png, jpg, doc, docx, Max. file size: 100 MB, Max. files: 4. Please upload your DD214 (Member 4 Copy), VA ROI, and Complete VA Rating Decision Letter (Not VA Annual Letter, No E-Benefit Statements)If there are responses above that you would prefer to provide over the phone (Versus electronic submission), please leave those sections blank and we will complete the intake via phone conversation.I Agree* We at QoLF are here to assist caregivers in improving the Quality of Life for their veteran and family. To insure you receive a positive outcome we ask that you actively participate in the process. Checking this box acknowledges willingness to stay in communication with QoLF. Lack of response to emails, texts, and phone calls will cause a termination in the program.HiddenWVFCP Forms AutoSent WVFCP Forms AutoSent EmailThis field is for validation purposes and should be left unchanged. Δ