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Thank you for your interest. To help us provide you with the most appropriate information, please complete and submit the following form ~ OR ~ Go to Contact Us for specific campus phone numbers.

For yourself or the person for who you are inquiring to live at AFRH
*=Required Information

Contact Information

If you are seeking information on behalf of a veteran, please include c/o Your Name in the address.

Marital Status: *
How did you hear about AFRH?
Publication/Advertisement: *
Please describe below if you learned about AFRH from someone like a friend, AFRH Resident, AFRH Staff Member, VA referral, family member or if you knew about AFRH because you lived or worked nearby, payroll deductions, visited AFRH, saw it on the news, etc. If you can provide a person’s name, they may be credited with the referral. If you attended an event or meeting and heard about AFRH there, please describe.

ELIGIBILITY INFORMATION

Military Category
To meet military eligibility, veterans must be non-commissioned for at least half of their service time, honorably discharged from the Armed Forces, and fall into at least one of the following categories:(select all applicable categories and types of service below)
C1: Retired after 20+ years of Active Duty Service
C2: Service-Connected Disability
C3: Served in a War Theater or received Hostile Fire Pay
C4: Female WWII Veteran
C5: Eligible for Non-Regular Retired Pay (non-regular service or early retirement)
None of the above
Army
Air Force
Coast Guard
Marines
Navy
Space Force
Beneficiary Spouse
None of the above
Enlisted Member or Non-Commissioned Officer (E-1 to E-9)
Warrant Officer (WO-1 to WO-5)
Limited-Duty Officer (O-1E to O-5E)
Commissioned Officer (O-1 To O-10)

Service Time: How long (Years/Months)  did you serve on active or inactive duty in the Armed Forces?

Full Active Career-Retired (min 20y active service)
Retired NGR (min 20y total active + inactive service)
Early Retirement / TERA with benefits (under 20y)
Disability/Medical Retirement with benefits (under 20y)
Honorably discharged, but ineligible for retirement benefits (under 20y)
Other
%
If you served during wartime or recieved Imminent Danger Pay, please list any wars/conflicts while you were on active-duty and identify service classification: did you serve within the officially designated War Theater (WT), did you qualify for Hostile Fire Pay (HFP) or Imminent Danger Pay (IDP), or were you assigned to provide support outside of the designated war theater during a Wartime Era (ERA)?
N/A
C2: Service-Connected Disability
C3: Served in a War Theater or received Hostile Fire Pay
C4: Female WWII Veteran
C5: Eligible for Non-Regular Retired Pay (non-regular service or early retirement)
None of the above
POW
Multiple awards, other:
Part A and B
Part A only
Underage / Not Eligible
Eligible, but not enrolled
Do not know
Other*
Tricare for Life
Tricare Prime/Select/Reserve
100% VA Service-Connected Benefits
Usually use VA (less than 100% SCD/IU)
unknown
Medicaid
Other insurance provider (name):
Support Need *
Fully independent, no support needs or limitations
Manages independently, but needs some support with daily tasks or hazard protection from family/caregivers
Needs home health care, rehab services, or other hired assistance
Needs support for decision making, cognitive impairment, or memory loss
Needs professional support for daily activities or unstable health conditions
Other limitations/support needs:*
Homeowner
Rental Unit
Community for Independent Seniors (55+)
Assisted Living or other facility
Living with a family member
Other:
1-3 months
4-7 months
8-12 months
12 – 24 months
Researching options
Other: