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Instructions and Data Privacy

To better serve you, please fill out this questionnaire. The information you provide is voluntary and will be kept confidential. You don't have to provide the information, but failure to do so could affect your eligibility for additional veteran program benefits.

Service Member Relationship

Please select the option below that best describes you:

Your Contact Information

Street Address
How would you prefer to be contacted?

Military Service Dates

Veterans and Active Service Member Questions

Do you have a service connected disability rated 10% or higher from the Veterans Administration?
Have you filed a claim for a service connected disability?
Were you discharged or released from active duty because of service-connected disability?
Have you left the military within the past three years AND been unemployed for at least 27 weeks at any time in the past year?
Are you homeless? This definition includes that you lack a fixed, regular, adequate nighttime residence OR your primary nighttime residence is a homeless shelter.
Are you 18 to 24 years old?
Are you a Viet Nam Era Veteran who served active duty in the military from August 5, 1964 to May 7, 1975? Or served in Viet Nam from February 28, 1961 to May 7, 1975?
Are you lacking a high school diploma or GED?
Are you, or your immediate family that you live with, currently receiving public assistance, and/or are you at a lower-income level according to your local area?
Do you have a criminal record?
Have you participated in the Transition Assistance Program (TAP), and are being referred to us by your last military commander?
Are you currently receiving services from the Minnesota Assistance Council for Veterans (MACV)?

Spouses and Caregivers Questions

Are you the spouse of a veteran rated at 100% disabled by the VA?  Or the spouse of a military member who was POW, MIA, KIA or who died of their service connected disability?
Are you the spouse or other family caregiver of a wounded, ill or injured active duty member?

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