After completing the application below you will need attach a .pdf file (scanned image) or .jpg file (picture image) of the following three documents:
These documents will be used for verification purposes and must accompany your application in order for your application to be reviewed.
Fields marked with an asterisk (*) are required.
Your First Name*
Your Last Name*
Street Address Line 2
Primary Phone Number*
Secondary Phone Number
I was Honorably Discharged from the*
US Air ForceUS ArmyUS Coast GuardUS MarinesUS Navy
Military Service Dates (enter date ranges below)
I received the following recognition / commendations while serving
My current health insurance provider is*
(Line 3 on Form 1095-A, Line 16 on Form 1095-b, Line 7 on Form 1095-C OR Insurer issuing Statement of Coverage)
Last year my Annual Household income as reported on my Federal Tax Return was*
(Line 37 on Form 1040, Line 21 on Form 1040a, or Line 4 on Form 1040EZ)
My current household size (dependents) as reported on my latest Federal Tax Return is*
(Line 6d on Form 1040 and Form 1040a)
Individual VeteranHousehold of 2Household of 3Household of 4Household of 5Household of 6
The following information WILL NOT be used in any way to determine eligibility for a Bridges For Heroes grant. This information is collected to assist Bridges For Heroes in obtaining additional funding and is always used in a collective/total population fashion and is not used to identify any individual.
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
Please upload your DD-214 Form* (PDF or JPG only, 4mb max file size):
Please upload one of the following: 1095-A, 1095-B, 1095-C, OR Insurer’s Statement of Coverage* (PDF or JPG only, 4mb max file size):
Please upload the first two pages of your most recent Federal Tax Return if you filed Form 1040 or Form 1040a, OR, upload the first page of your most recent Federal Tax Return if you filed Form 1040EZ* (PDF or JPG only, 4mb max file size):
American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.”
Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa