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Veterans Assistance Project

Name:

Phone:

Email:

Address:

City: State: Zip:

Are you seeking assistance with your VA Disability Benefits? Yes No

If Yes, please briefly describe what type of assistance you are seeking:

Date of Service:

Type of Discharge:

Have you previously applied for VA Disability Benefits? Yes No,

If Yes, has it been denied? Yes No,

Reason for denial:

Please choose the date and time you would prefer to be scheduled for to attend the Veterans clinic:

July 24th (Thursday) 2 pm

July 24th (Thursday) 3 pm

How did you hear about our Project?
311
Mayor's Office of Veterans Affairs Website
New York City Bar Website
Flyer
Word of Mouth
VA Hospital
VA Office
Other