Armed Forces Retirement Home Request Application

Contact Information

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

Veteran’s Name *

Address *

City, ST Zip: *

Telephone #: *

Email

Campus: *

Birthdate *

Marital Status: *

Other: *

Who is applying? *

Veteran Only

Couple – Non-military Spouse

Couple – Dual-military eligible

How did you hear about AFRH?

Publication/Advertisement *

Other Advertisement: *

Military Associations/Events *

Other *

Retiree Appreciation Day Event at base *

Referrals or other sources: *

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.

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)

Category *

C1: Age 60+ with 20+ years Active Duty

C2: Service-Connected Disability (over 50%)

C3: Served in a war theater or had hostile fire pay

C4: Female WWII Veteran

None of the above

Type(s) of Service *

Enlisted

Warrant Officer / Limited Duty Officer

Commissioned Officer

Military Career

Describe veteran’s military career: List all military service branches that apply (active and inactive duty), type of service, rank, grade, time, service-connected disability, retirement, wartime service, awards etc.

Military Branches:

Active (Regular Military) *

Inactive (Guard/Reserves) *

Rank/Grade *

Service Time:

How long (Y/M/D) did you serve on active or inactive duty in the Armed Forces?

Enlisted/Non-Comm: * Active-Duty

Commissioned Officer: Active-Duty

Nat’l Guard/Reserves: Inactive-Duty

VA Service-Connected Rating: * % SCD

Retired: *

Full Active Career-Retired (min 20y)

Retired (min 20y total active + inactive)

Early Retirement / TERA (under 20y)

Disability/Medical Retirement (under 20y)

No, not receiving retirement pay

Other:

Other: *

Wartime Service

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)?

Wars/Class: (list all) *

Examples: Vietnam/WT, Korea/ERA, Submarine Duty/HFP, Liberia/IDP, none, etc. Note: Any officially designated war theaters will be listed on the veteran’s DD-214 but IDP/HFP hostile zones may not be included. (additional documentation may be needed for those applying under Category 3 with hostile fire pay as proof of eligibility)

Service Awards: *

Multiple awards, other: *

Insurance

All applicants must be enrolled in acceptable health insurance prior to being approved for admission. Anyone over 65 must have both Medicare A&B and Supplemental Insurance or 100% VA benefits. Those under 65 who have less than a 100% VA disability rating, must have major medical insurance covering hospitalization, medical visits and prescriptions.

Medicare *

Part A and B

Part A only

Underage / Not Eligible

Eligible, but not enrolled

unknown

other*:

other*: *

Supplemental/Other Insurance*: *

Tricare for Life

Tricare Prime/Select/Reserve

100% VA Service-Connected Benefits

Usually use VA (less than 100% SCD/IU)

None (no supplement or other insurance)

Medicaid

Other insurance provider (name):

Other insurance provider (name)*: *

Health / Independence

Support needs *

1) None, fully independent

2) Independent, but needs some support with daily tasks or hazard protection from family/caregivers

3) Needs home health care, rehab services, or other hired assistance

4) Needs support for decision making, cognitive impairment, or memory loss

5) Needs the support of an assisted living, skilled nursing, or long term care facility

6) Other limitations/support needs:*

Other limitations/support needs: *

Housing *

Homeowner

Apartment / Rental

Independent Senior Community

Assisted Living Facility

Short-Term Rehab or Skilled Nursing Home

Long-term or Memory Care Facility

Live with family member

Other:

Other: *

How soon would you be interested in moving if you are eligible?

Timeframe: *

Other: *

Comments

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