Tampa Polytrauma Rehabilitation Center – Financial Assistance Application

 

Requirements for TAMPA POLYTRAUMA REHABILITATION CENTER Assistance Application:

  • Assistance limited to post 9/11 veterans and active service members in VA hospitals or mental health, rehabilitation or substance abuse programs. 
  • Members of the Reserves or National Guard must be injured in military service to qualify for assistance.
  • Must show proof of service-connection rating
  • Must include a valid & legible copy of your DD214 or Statement of Service Letter.
  • Must include photo copy of state-issued ID (driver’s license or state ID).
  • A military Point-of-Contact including phone number and email address is required. This person should be a VA case worker or mental/physical health counselor who understands your history and current situation, and has your written consent to discuss your case.
  • Copies of bills for which you are requesting payment assistance. *W9 required for all rental payments.
  • The application must be complete. An incomplete application cannot be processed.

Important Notes

  • One-time assistance only
  • Assistance could take 3-4 weeks. Cases are handled on a first come first serve basis.
  • Any altered or falsified documentation is considered a felony
 
Fill out the web based application form.
(Strongly Preferred)

Print-Based Application

To submit a paper-based application: download, print, and fill out the application PDF and submit it–along with your DD214 or Statement of Service Letter –in one of the following three ways:

  • Scan and email them to gethelp@saluteinc.org
  • Fax them to (847) 359-8818
  • Mail it to SALUTE, INC.
    P.O. Box 2663
    Palatine, IL 60078

    Web-Based Application


    Personal Information

    Veteran Applicant Information:





    Date of Birth:

    Ethnicity:

    Are you employed?

    Marital Status:

    Is your spouse employed?

    Do you have dependent children under age 18? / How Many?

    Branch of Service:

    Dates of Active/Reserve Duty:

    to

    After your discharge, which of the following applies?

    Current Service Connection Rating ( Enter a number between 1 and 100 ):

    Injuries:

    Do you require a caregiver?

    Have you ever received financial assistance from SALUTE, INC. or from any other organizations?

    Mandatory Point of Contact Information

    Military/VA Case Worker/Mental or Physical Health Counselor Point of Contact:

    The verification & release of all case information must be provided in order to process application.

    Financial Record

    Monthly Income

    Monthly Needs/Expenses

    Goals & Objectives

    What are you requesting help with?

    How will your situation be financially improved in 3-6 months assuming SALUTE, INC. gives you financial assistance?

    Required File Uploads

    Please attach scans or PDFs of at least these three (3) required files:

    - Your DD214 or Statement of Service Letter (required)

    - Your state issued ID card (Driver's License or State ID) (required)

    - Your VA documentation of injuries & disability rating (required)

    Include any additional files you would like us to consider, like bills or other documents.

    This form will accept up to 10 files in total, up to 12MB in size.

    Files can be PDFs, Word Docs, or image files (png, jpg, jpeg, gif).

    Are you a representative?

    Are you submitting this application on behalf of the Veteran Applicant?



    Verification and Submission of Form


    What email address should receive confirmation of this application and be used for application communications?

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