Tampa Polytrauma Rehabilitation Center – Financial Assistance Application

Requirements for TAMPA POLYTRAUMA REHABILITATION CENTER Assistance Application

Must include a valid & legible copy of your DD214 or Statement of Service Letter.
Must include photo copy of state issued ID (driver’s license or state ID).
Must include VA documentation of injuries & disability rating.
A mandatory Point-of-Contact including phone number and email address is required. This person should be a VA case worker or mental/physical health counselor who understands your history and current situation, and has your written consent to discuss your case.
Copies of bills for which you are requesting payment assistance. *W9 required for all rental payments.
The application must be complete. An incomplete application cannot be processed.

Important Notes

One time assistance only
Assistance could take 3-4 weeks. Cases are handled on a first come first serve basis.
Any altered or falsified documentation is considered a felony

Fill out the web based application form.
(Strongly Preferred)

Print-Based Application

To submit a paper-based application: download, print, and fill out the application PDF and submit it–along with your DD214 or Statement of Service Letter –in one of the following three ways:

Scan and email them to gethelp@saluteinc.org
Fax them to (847) 359-8818
Mail it to SALUTE, INC.
P.O. Box 2663
Palatine, IL 60078

Web-Based Application

Personal Information

Veteran Applicant Information:

Date of Birth:

Ethnicity:

Are you employed?

Marital Status:

Is your spouse employed?

Do you have dependent children under age 18? / How Many?

Branch of Service:

Dates of Active/Reserve Duty:

_to

After your discharge, which of the following applies?

Current Service Connection Rating ( Enter a number between 1 and 100 ):

Injuries:

Do you require a caregiver?

Have you ever received financial assistance from SALUTE, INC. or from any other organizations?

Mandatory Point of Contact Information

Military/VA Case Worker/Mental or Physical Health Counselor Point of Contact:

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.

The verification & release of all case information must be provided in order to process application.

Financial Record

Monthly Income

Monthly Needs/Expenses

Goals & Objectives

What are you requesting help with?

How will your situation be financially improved in 3-6 months assuming SALUTE, INC. gives you financial assistance?

Required File Uploads

Please attach scans or PDFs of at least these three (3) required files:

- Your DD214 or Statement of Service Letter (required)

- Your state issued ID card (Driver's License or State ID) (required)

- Your VA documentation of injuries & disability rating (required)

Include any additional files you would like us to consider, like bills or other documents.

This form will accept up to 10 files in total, up to 12MB in size.

Files can be PDFs, Word Docs, or image files (png, jpg, jpeg, gif).

Are you a representative?

Are you submitting this application on behalf of the Veteran Applicant?

Verification and Submission of Form

What email address should receive confirmation of this application and be used for application communications?

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.

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