{"id":2343,"date":"2021-02-04T15:07:25","date_gmt":"2021-02-04T15:07:25","guid":{"rendered":"https:\/\/www.saluteinc.org\/?page_id=2343"},"modified":"2025-05-12T16:08:08","modified_gmt":"2025-05-12T16:08:08","slug":"shepherd-center-financial-assistance-application","status":"publish","type":"page","link":"https:\/\/www.saluteinc.org\/shepherd-center-financial-assistance-application\/","title":{"rendered":"Shepherd Center &#8211; Financial Assistance Application"},"content":{"rendered":"\r\n<p><strong>Requirements for SHEPHERD CENTER Assistance Application:<\/strong><\/p>\r\n<ul>\r\n<li><strong>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, \u00a0rehabilitation and substance abuse programs.<\/strong>\u00a0<\/li>\r\n<li><strong>Must provide letter from a doctor, therapist, or case manager confirming participation in ongoing inpatient or outpatient program<\/strong>.<\/li>\r\n<li><strong>Reason for financial assistance must be medical or military related due to VA service-connected rating<\/strong>.<\/li>\r\n<li>Must show proof of<strong> VA service-connection rating.<\/strong><\/li>\r\n<li>Must provide a valid and legible copy of your<strong> DD214<\/strong> or Statement of Service Letter for Active Duty, Reserves or National Guard.<\/li>\r\n<li>Must reside in the United States and provide a <strong>state-issued ID <\/strong>(Driver\u2019s License or State ID).<\/li>\r\n<li>Must include the monthly billing statement for the payment assistance you are requesting<em>.\u00a0 Screenshots are NOT accepted.<\/em><\/li>\r\n<li>Rental assistance requires copy of lease and the landlord\u2019s W9 tax form.<\/li>\r\n<\/ul>\r\n<p><strong>Important Notes:<\/strong><\/p>\r\n<ul>\r\n<li><strong>One-time<\/strong> assistance only.<\/li>\r\n<li>Allow 3-4 weeks for processing.<\/li>\r\n<li>Any altered or falsified documentation is considered a felony.<\/li>\r\n<li><em>Disclaimer:\u00a0 Meeting these requirements does not guarantee assistance.<\/em><\/li>\r\n<\/ul>\r\n<div class=\"page\" title=\"Page 1\">\r\n<p>&nbsp;<\/p>\r\n<\/div>\r\n<div style=\"padding-bottom: 24px; text-align: center; font-size: 1.2em;\"><a href=\"#web-application\">Fill out the web based application form.<\/a><br \/><strong>(Strongly Preferred)<\/strong><\/div>\r\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; padding-bottom: 12px;\" \/>\r\n\r\n\r\n<h4 class=\"wp-block-heading\">Print-Based Application<\/h4>\r\n\r\n\r\n\r\n<p style=\"line-height: 1.4em;\">To submit a paper-based application: <a href=\"https:\/\/www.saluteinc.org\/wp-content\/uploads\/2025\/05\/SHEPHERD-Center-Financial-Asst-Form-2025.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">download,<\/a> print, and fill out the application PDF and submit it\u2013<em>along with your DD214 or Statement of Service Letter <\/em>\u2013in <u>one<\/u> of the following three ways:<\/p>\r\n\r\n\r\n\r\n<ul>\r\n<li class=\"tp12\">Fax them to (847) 359-8818 (preferred method of submission)<\/li>\r\n<li id=\"web-application\" class=\"tp12\">Scan and email them to <a title=\"Use this link to generate your Financial Assistance Form email to us\" href=\"mailto:gethelp@saluteinc.org?subject=New%20Financial%20Assistance%20Application\" target=\"_blank\" rel=\"noopener noreferrer\">gethelp@saluteinc.org<\/a><\/li>\r\n<li class=\"tp12\">Mail it to SALUTE, INC.<br \/>P.O. Box 2663<br \/>Palatine, IL 60078<\/li>\r\n<\/ul>\r\n\r\n\r\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; padding-bottom: 12px;\" \/>\r\n\r\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2294-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2294\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/2343#wpcf7-f2294-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2294\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.5\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2294-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:2294,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;caregiver-required&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;InjuryStatus&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;service-connected-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;InjuryStatus&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Please choose one&quot;},{&quot;if_field&quot;:&quot;InjuryStatus&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;I have been rated unemployable&quot;},{&quot;if_field&quot;:&quot;InjuryStatus&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;I am not injured&quot;}]},{&quot;then_field&quot;:&quot;married-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;MaritalStatus&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Married&quot;}]},{&quot;then_field&quot;:&quot;injured-selected&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;InjuryStatus&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;I am not injured&quot;},{&quot;if_field&quot;:&quot;InjuryStatus&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;I have been rated unemployable&quot;},{&quot;if_field&quot;:&quot;InjuryStatus&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Please choose one&quot;}]},{&quot;then_field&quot;:&quot;assistance-received&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;ReceivedAssistance&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;caregiver-required&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;CaregiverRequired&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;has-representative&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;IsRepresentative&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;notice_dismissed_rollback-cf7-5.6.3&quot;:true}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"row\" style=\"padding-bottom: 18px;\">\n\t<h4>Web-Based Application\n\t<\/h4>\n<\/div>\n<div class=\"row\" style=\"padding-bottom: 18px;\">\n\t<h3><br \/>\nPersonal Information\n\t<\/h3>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Veteran Applicant Information:\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"FirstName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"FirstName\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"LastName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"LastName\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"StreetAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Street Address\" value=\"\" type=\"text\" name=\"StreetAddress\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"City\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"City\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"State\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"State\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Zip\" value=\"\" type=\"text\" name=\"Zip\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone (with area code)\" value=\"\" type=\"tel\" name=\"Phone\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"EmailAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"EmailAddress\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Date of Birth:\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"YYYY-MM-DD\" value=\"\" type=\"date\" name=\"DOB\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Ethnicity:\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Ethnicity\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Ethnicity\"><option value=\"Please select one\">Please select one<\/option><option value=\"American Indian\/Alaskan Native\">American Indian\/Alaskan Native<\/option><option value=\"Asian\">Asian<\/option><option value=\"Hispanic\/Latino\">Hispanic\/Latino<\/option><option value=\"Black\/African American\">Black\/African American<\/option><option value=\"Native Hawaiian or Pacific Islander\">Native Hawaiian or Pacific Islander<\/option><option value=\"Multi Ethnic\">Multi Ethnic<\/option><option value=\"White\">White<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Are you employed?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Employed\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Employed\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Marital Status:\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"MaritalStatus\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"MaritalStatus\"><option value=\"Single\">Single<\/option><option value=\"Married\">Married<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Separated\">Separated<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"married-selected\" data-orig_data_id=\"married-selected\"  data-class=\"wpcf7cf_group\">\n\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"SpouseName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Spouse&#039;s full name\" value=\"\" type=\"text\" name=\"SpouseName\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t<p>Is your spouse employed?\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"SpouseEmployed\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"SpouseEmployed\"><option value=\"select one\">select one<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Do you have dependent children under age 18? \/ How Many?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Children\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Children\"><option value=\"Please select one\">Please select one<\/option><option value=\"No\">No<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Branch of Service:\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Branch\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Branch\"><option value=\"Please select one\">Please select one<\/option><option value=\"Army\">Army<\/option><option value=\"Navy\">Navy<\/option><option value=\"Air Force\">Air Force<\/option><option value=\"Marines\">Marines<\/option><option value=\"Coast Guard\">Coast Guard<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Dates of Active\/Reserve Duty:\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ActiveFrom\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Began Duty (YYYY-MM-DD)\" value=\"\" type=\"date\" name=\"ActiveFrom\" \/><\/span><sub style=\"padding: 16px 12px 0 0;\">to<\/sub><span class=\"wpcf7-form-control-wrap\" data-name=\"ActiveTo\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ended Duty (YYYY-MM-DD)\" value=\"\" type=\"date\" name=\"ActiveTo\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>After your discharge, which of the following applies?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"InjuryStatus\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"InjuryStatus\"><option value=\"Please choose one\">Please choose one<\/option><option value=\"I am not injured\">I am not injured<\/option><option value=\"I am service connected and currently rated @...\">I am service connected and currently rated @...<\/option><option value=\"I am currently being evaluated\/re-evaluated for service connection rating\">I am currently being evaluated\/re-evaluated for service connection rating<\/option><option value=\"I have a permanent disability\">I have a permanent disability<\/option><option value=\"I have been rated unemployable\">I have been rated unemployable<\/option><option value=\"I am currently undergoing a rehabilitation or recuperation program\">I am currently undergoing a rehabilitation or recuperation program<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"injured-selected\" data-orig_data_id=\"injured-selected\"  data-class=\"wpcf7cf_group\">\n\t<div data-id=\"service-connected-selected\" data-orig_data_id=\"service-connected-selected\"  data-class=\"wpcf7cf_group\">\n\t\t<div class=\"row\" style=\"padding: 12px 0 0 32px;\">\n\t\t\t<p>Current Service Connection Rating (&nbsp;<em style=\"color:red;\">Enter a number between 1 and 100<\/em>&nbsp;):\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"SvcConnectionRating\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-invalid=\"false\" value=\"0\" type=\"number\" name=\"SvcConnectionRating\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 12px 0 0 32px;\">\n\t\t<p>Injuries:\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ServiceInjuries\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Briefly list the injuries incurred during your time in service\" value=\"\" type=\"text\" name=\"ServiceInjuries\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 12px 0 0 32px;\">\n\t\t<p>Do you require a caregiver?\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverRequired\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"CaregiverRequired\"><option value=\"Please select one\">Please select one<\/option><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"caregiver-required\" data-orig_data_id=\"caregiver-required\"  data-class=\"wpcf7cf_group\">\n\t\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"CaregiverName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Caregiver&#039;s Full Name\" value=\"\" type=\"text\" name=\"CaregiverName\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Have you ever received financial assistance from SALUTE, INC. or from any other organizations?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 8px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ReceivedAssistance\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"ReceivedAssistance\"><option value=\"Select one\">Select one<\/option><option value=\"No\">No<\/option><option value=\"Yes\">Yes<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"assistance-received\" data-orig_data_id=\"assistance-received\"  data-class=\"wpcf7cf_group\">\n\t<div class=\"row\" style=\"padding: 8px 0 0 32px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"PreviousAssistance\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"List sources &amp; amounts of previous aid\" value=\"\" type=\"text\" name=\"PreviousAssistance\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; margin-top: 22px;\" \/>\n<div class=\"row\" style=\"padding: 18px 0px;\">\n\t<h3>Mandatory Point of Contact Information\n\t<\/h3>\n<\/div>\n<div class=\"row\" style=\"padding-top: 6px;\">\n\t<p>Military\/VA Case Worker\/Mental or Physical Health Counselor Point of Contact:\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ContactName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Full name\" value=\"\" type=\"text\" name=\"ContactName\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ContactTitle\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Title\" value=\"\" type=\"text\" name=\"ContactTitle\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ContactEmail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"ContactEmail\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ContactPhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"tel\" name=\"ContactPhone\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"ContactPhoneExt\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"Extension\" value=\"\" type=\"number\" name=\"ContactPhoneExt\" \/><\/span>\n\t<\/p>\n<\/div>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Authorized\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"Authorized\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\"><i><\/i> <span style=\"font-size: 1em;\">I have notified my Point of Contact (POC) that a SALUTE representative will be contacting them and I have authorized my POC to discuss my case with the SALUTE representative. <\/span><\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<div class=\"row\">\n\t<p>The verification & release of all case information must be provided in order to process application.\n\t<\/p>\n<\/div>\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; margin-top: 22px;\" \/>\n<div class=\"row\" style=\"padding: 18px 0px;\">\n\t<h3>Financial Record\n\t<\/h3>\n<\/div>\n<div class=\"row\">\n\t<p style=\"font-size: 1.2em;\"><strong>Monthly Income<\/strong>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"LES-SLE-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"LES-Separation Leave of Earnings Statement\" value=\"\" type=\"text\" name=\"LES-SLE-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"VA-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Veterans Compensations\/ Pension from VA\" value=\"\" type=\"text\" name=\"VA-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"SS-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Social Security Benefits\" value=\"\" type=\"text\" name=\"SS-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"FS-SA-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Food Stamps\/ State Aide\" value=\"\" type=\"text\" name=\"FS-SA-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"work-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Work Income\" value=\"\" type=\"text\" name=\"work-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"child-support-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Child Support\" value=\"\" type=\"text\" name=\"child-support-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"unemployment-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Unemployment\" value=\"\" type=\"text\" name=\"unemployment-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"spouse-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Earnings of Spouse\" value=\"\" type=\"text\" name=\"spouse-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"loans-GIB-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Loans\/GI Bill\" value=\"\" type=\"text\" name=\"loans-GIB-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver-pay-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Caregivers Pay\" value=\"\" type=\"text\" name=\"caregiver-pay-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"addl-income\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Additional Income\" value=\"\" type=\"text\" name=\"addl-income\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p style=\"font-size: 1.2em;\"><strong>Monthly Needs\/Expenses<\/strong>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mortgage-rent-paymt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Mortgage\/Rent\" value=\"\" type=\"text\" name=\"mortgage-rent-paymt\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"car-paymt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Car Payment\" value=\"\" type=\"text\" name=\"car-paymt\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"car-insurance-paymt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Car Insurance\" value=\"\" type=\"text\" name=\"car-insurance-paymt\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"utility-paymt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Utilities\" value=\"\" type=\"text\" name=\"utility-paymt\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phone-paymt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"phone-paymt\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-paymt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other\" value=\"\" type=\"text\" name=\"other-paymt\" \/><\/span>\n\t<\/p>\n<\/div>\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; margin-top: 22px;\" \/>\n<div class=\"row\" style=\"padding: 18px 0px;\">\n\t<h3>Goals & Objectives\n\t<\/h3>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>What are you requesting help with?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"critical-needs\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please list the most critical needs in order of importance.\" value=\"\" type=\"text\" name=\"critical-needs\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>How will your situation be financially improved in 3-6 months assuming SALUTE, INC. gives you financial assistance?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\" >\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"short-term-goal\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter\" value=\"\" type=\"text\" name=\"short-term-goal\" \/><\/span>\n\t<\/p>\n<\/div>\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; margin-top: 22px;\" \/>\n<div class=\"row\" style=\"padding: 18px 0px;\">\n\t<h3>Required File Uploads\n\t<\/h3>\n<\/div>\n<div class=\"row\">\n\t<p>Please attach scans or PDFs of at least these three (3) required files:\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding: 18px 0 0 8px;\">\n\t<p>- Your DD214 or Statement of Service Letter (required)\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding: 6px 0 0 8px;\">\n\t<p>- Your state issued ID card (Driver's License or State ID) (required)\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding: 6px 0 18px 8px;\">\n\t<p>- Your VA documentation of injuries & disability rating (required)\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 6px;\">\n\t<p>Include any additional files you would like us to consider, like bills or other documents.\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p><i>This form will accept up to 10 files in total, up to 12MB in size<\/i>.\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p>Files can be PDFs, Word Docs, or image files (png, jpg, jpeg, gif).\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 24px;\">\n\t<p><span class=\"wpcf7-form-control-wrap dropuploader-830\" style=\"position: static;\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-dropuploader wpcf7-validates-as-required\" accept=\"image\/jpeg,image\/jpeg,image\/png,image\/gif,application\/pdf,pdf,application\/msword,doc,application\/vnd.openxmlformats-officedocument.wordprocessingml.document,docx\" data-maxfilesize=\"12000000\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"dropuploader-830[]\" multiple=\"multiple\" data-count=\"10\" \/><\/span>\n\t<\/p>\n<\/div>\n<!-- FILE ATTACHMENT LINE above -->\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; margin-top: 22px;\" \/>\n<div class=\"row\" style=\"padding: 18px 0px;\">\n\t<h3>Are you a representative?\n\t<\/h3>\n<\/div>\n<div class=\"row\">\n\t<p>Are you submitting this application on behalf of the Veteran Applicant?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"IsRepresentative\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"IsRepresentative\"><option value=\"Please select one\">Please select one<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"has-representative\" data-orig_data_id=\"has-representative\"  data-class=\"wpcf7cf_group\">\n\t<div class=\"row\" style=\"padding: 8px 0px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"RepName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Your full name (Required)\" value=\"\" type=\"text\" name=\"RepName\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"RepRelationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Relationship to Veteran (Required)\" value=\"\" type=\"text\" name=\"RepRelationship\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 8px 0px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"RepAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Your Address (Required)\" value=\"\" type=\"text\" name=\"RepAddress\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"row\" style=\"padding: 8px 0px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"RepPhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Your Phone, with area code (Required)\" value=\"\" type=\"text\" name=\"RepPhone\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"RepEmail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Your Email (Required)\" value=\"\" type=\"email\" name=\"RepEmail\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr style=\"border-left: 0; border-top: 1px solid #adadad; margin-top: 22px;\" \/>\n<div class=\"row\" style=\"padding: 18px 0px;\">\n\t<h3>Verification and Submission of Form\n\t<\/h3>\n<\/div>\n<div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Signature\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your Name\" value=\"\" type=\"text\" name=\"Signature\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"AppliedDate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date (YYYY-MM-DD)\" value=\"\" type=\"date\" name=\"AppliedDate\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"row\">\n\t<p>What email address should receive confirmation of this application and be used for application communications?\n\t<\/p>\n<\/div>\n<div class=\"row\" style=\"padding-top: 12px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"CommEmail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Confirmation Email\" value=\"\" type=\"email\" name=\"CommEmail\" \/><\/span>\n\t<\/p>\n<\/div>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Authorized\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"Authorized\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\"><i><\/i> <span style=\"font-size: 1em;\">I certify the above information to be true and correct. I authorize verification\/release of the information that I am providing on this application. Disclosure of information on this form is voluntary. Failure to provide the requested information, however, will prohibit the processing of this application. In accordance with applicable laws, SALUTE, INC. will maintain confidentiality regarding the application and any aid given or denied except as required to process this or subsequent applications, or an otherwise required by law.<\/span><\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>[dropuploader_message \"Files are uploading...\"]\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n\r\n\r\n\r\n<p>&nbsp;<\/p>\r\n","protected":false},"excerpt":{"rendered":"<p>Requirements for SHEPHERD 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, \u00a0rehabilitation and substance abuse programs.\u00a0 Must provide letter from a doctor, therapist, or case manager confirming participation in ongoing inpatient or outpatient program. Reason &hellip; <a href=\"https:\/\/www.saluteinc.org\/shepherd-center-financial-assistance-application\/\">Continued<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"templates\/template-application.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-2343","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.saluteinc.org\/wp-json\/wp\/v2\/pages\/2343","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.saluteinc.org\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.saluteinc.org\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.saluteinc.org\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.saluteinc.org\/wp-json\/wp\/v2\/comments?post=2343"}],"version-history":[{"count":0,"href":"https:\/\/www.saluteinc.org\/wp-json\/wp\/v2\/pages\/2343\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.saluteinc.org\/wp-json\/wp\/v2\/media?parent=2343"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}