Armed Forces Retirement Home Request Application

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.

Veteran’s Name: *

Address: *

City: *

State: *

Zip Code: *

Telephone #: *

Email:

Campus: *

Birthdate: *

Marital Status: *

SPOUSE’S FULL NAME: (if applying for admission with the veteran)

Who is applying? *

How did you hear about AFRH?

Publication/Advertisement: *

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. 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)

Category: *


C1: Retired after 20+ years of Active Duty Service	C1: Retired after 20+ years of Active Duty Service
C2: Service-Connected Disability	C2: Service-Connected Disability
C3: Served in a War Theater or received Hostile Fire Pay	C3: Served in a War Theater or received Hostile Fire Pay
C4: Female WWII Veteran	C4: Female WWII Veteran
C5: Eligible for Non-Regular Retired Pay (non-regular service or early retirement)	C5: Eligible for Non-Regular Retired Pay (non-regular service or early retirement)
None of the above	None of the above

Military Branches: *


Army	Army
Air Force	Air Force
Coast Guard	Coast Guard
Marines	Marines
Navy	Navy
Space Force	Space Force
Beneficiary Spouse	Beneficiary Spouse
None of the above	None of the above

FINAL Rank/Grade: *

Type(s) of Service: *


Enlisted Member or Non-Commissioned Officer (E-1 to E-9)	Enlisted Member or Non-Commissioned Officer (E-1 to E-9)
Warrant Officer (WO-1 to WO-5)	Warrant Officer (WO-1 to WO-5)
Limited-Duty Officer (O-1E to O-5E)	Limited-Duty Officer (O-1E to O-5E)
Commissioned Officer (O-1 To O-10)	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?

TOTAL ACTIVE SERVICE TIME: *

TOTAL NAT’L GUARD/RESERVE TIME:

RETIRED / DISCHARGED: *


Full Active Career-Retired (min 20y active service)	Full Active Career-Retired (min 20y active service)
Retired NGR (min 20y total active + inactive service)	Retired NGR (min 20y total active + inactive service)
Early Retirement / TERA with benefits (under 20y)	Early Retirement / TERA with benefits (under 20y)
Disability/Medical Retirement with benefits (under 20y)	Disability/Medical Retirement with benefits (under 20y)
Honorably discharged, but ineligible for retirement benefits (under 20y)	Honorably discharged, but ineligible for retirement benefits (under 20y)
Other	Other

Other *:

SERVICE-CONNECTED DISABILITY RATING*: %

War Theaters / Hostile Areas: (list all) *

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)?

Service Awards: *


N/A	N/A
C2: Service-Connected Disability	C2: Service-Connected Disability
C3: Served in a War Theater or received Hostile Fire Pay	C3: Served in a War Theater or received Hostile Fire Pay
C4: Female WWII Veteran	C4: Female WWII Veteran
C5: Eligible for Non-Regular Retired Pay (non-regular service or early retirement)	C5: Eligible for Non-Regular Retired Pay (non-regular service or early retirement)
None of the above	None of the above
POW	POW
Multiple awards, other:	Multiple awards, other:

Multiple awards, other:*

Health Insurance

Medicare: *


Part A and B	Part A and B
Part A only	Part A only
Underage / Not Eligible	Underage / Not Eligible
Eligible, but not enrolled	Eligible, but not enrolled
Do not know	Do not know
Other*	Other*

Other:*

Supplemental/Other Insurance: *


Tricare for Life	Tricare for Life
Tricare Prime/Select/Reserve	Tricare Prime/Select/Reserve
100% VA Service-Connected Benefits	100% VA Service-Connected Benefits
Usually use VA (less than 100% SCD/IU)	Usually use VA (less than 100% SCD/IU)
unknown	unknown
Medicaid	Medicaid
Other insurance provider (name):	Other insurance provider (name):

Other insurance provider (name): *

Health / Independence

	Support Need *
Fully independent, no support needs or limitations	Fully independent, no support needs or limitations
Manages independently, but needs some support with daily tasks or hazard protection from family/caregivers	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 home health care, rehab services, or other hired assistance
Needs support for decision making, cognitive impairment, or memory loss	Needs support for decision making, cognitive impairment, or memory loss
Needs professional support for daily activities or unstable health conditions	Needs professional support for daily activities or unstable health conditions
Other limitations/support needs:*	Other limitations/support needs:*

Other limitations/support needs: *

What is your current living arrangement?


Homeowner	Homeowner
Rental Unit	Rental Unit
Community for Independent Seniors (55+)	Community for Independent Seniors (55+)
Assisted Living or other facility	Assisted Living or other facility
Living with a family member	Living with a family member
Other:	Other:

Other*

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


1-3 months	1-3 months
4-7 months	4-7 months
8-12 months	8-12 months
12 – 24 months	12 – 24 months
Researching options	Researching options
Other:	Other:

Other: *

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