Tampa Polytrauma Rehabilitation Center – Financial Assistance Application

 

Requirements for TAMPA POLYTRAUMA REHABILITATION CENTER Assistance Application:

  • Assistance limited to post 9/11 (2001) Veterans, Active Duty Service Members, including Reservists and National Guard members in VA hospitals as well as mental health,  rehabilitation and substance abuse programs. 
  • Must provide letter from a doctor, therapist, or case manager confirming participation in ongoing inpatient or outpatient program.
  • Reason for financial assistance must be medical or military related due to VA service-connected rating.
  • Must show proof of VA service-connection rating.
  • Must provide a valid and legible copy of your DD214 or Statement of Service Letter for Active Duty, Reserves or National Guard.
  • Must reside in the United States and provide a state-issued ID (Driver’s License or State ID).
  • Must include the monthly billing statement for the payment assistance you are requesting.  Screenshots are NOT accepted.
  • Rental assistance requires copy of lease and the landlord’s W9 tax form.

Important Notes:

  • One-time assistance only.
  • Allow 3-4 weeks for processing.
  • Any altered or falsified documentation is considered a felony.
  • Disclaimer:  Meeting these requirements does not guarantee assistance.

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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