2. Monroe County Veterans Affairs Veteran Intake Form

   Please complete all fields to the best of your ability. All information will be kept confidential in accordance with applicable privacy laws.

4. Veteran Information
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip*
15. Email Address
16. Phone*
18. Full Social Security Number*
19. Date of Birth*
    Date of Birth
23. Military Service Information
25. Branch of Service*
27. From and To*
    From and To Start Date

    —

    From and To End Date
28. Expected/Actual Discharge Date*
    Expected/Actual Discharge Date
30. Character of Discharge

    (If known)

32. Services Requested*

    1. VA Compensation (Disability)
    2. VA Healthcare Enrollment
    3. VA Education Benefits (GI Bill, VRE)
    4. Burial Benefits or Pre-Need Eligibility
    5. Survivor Benefits (DIC, Death Pension, CHAMPVA)
    6. Non-Service Connected Pension
    7. Referral to Monroe County Social Services
    8. Other
34. If other, please explain
38. Certification*

    1. Yes

    I certify that the statements on this form are true and correct to the best of my knowledge and belief and that by typing my name and dating this document below and submitting this form I am signing this document. 

40. Full Name*
41. Date*
Leave This Blank:


44. Submit

* indicates a required field