HEA L T H CA R E F O R
REENTRY VETERANS
PR O GR A M (H CR V)
Healthcare for Reentry Veterans (HCRV) is a program designed to address the community
reentry needs of veterans regarding release from state or federal prison.

GUIDEBOOK FOR VETERANS
INCARCERATED IN
FLORIDA, SOUTHERN GEORGIA, PUERTO
RICO, AND THE U.S. VIRGIN ISLANDS

For follow up in prisons from Hernando
C.I. and points NORTH contact:

Taylor J. Alyea, MSW
Health Care for Reentry
Veteran Specialist
1002 NW 23rd Avenue,
Gainesville, FL 32609
(352) 379-4955
Fax: 352) 379-2748
For follow up in prisons from Orlando
and points SOUTH contact:

Michelle Carroll, LICSW
Health Care for Reentry
Veteran Specialist
7305 N. Military Trail
W. Palm Beach, FL 33410
Phone: (561) 248-3470
Fax: (561) 422-5309
1

FORWARD
Dear Veteran,
This guidebook is made for you. The information it offers can help you as you go from being
incarcerated to returning to life within your own community. You are encouraged to start following the
suggestions offered in this guidebook during the last six months of your incarceration. Begin by
enrolling with the VA and learning what resources are available in your home area. Through your
efforts and with the assistance of the people and programs listed in this guidebook, your transition can be
a success.
Taylor J. Alyea and Michelle Carroll—
Revised: February, 2009. HCHV Gainesville Homeless Program Staff - Mary Jo Delahunty, Charlotte
Matthews, and Taylor J. Alyea
Original: Veterans Incarcerated Workgroup—Miami/Tallahassee, Florida
Acknowledgements: We would like to recognize and thank: 1) the National Coalition for Homeless
Veterans which provided basic concepts and core information for this guide through its “Planning for
Your Release” guide funded by the U.S. Department of Labor; 2) Veterans Incarcerated Workgroup of
Walla Walla, WA, for the concept of state-specific information in its “Guidebook for Incarcerated
Veterans” and for allowing the use of its guide as a template; 3) Vietnam Veterans of America, Inc. for
developing the first incarcerated veterans guidebook, which has inspired and informed these efforts; and
4) We also appreciate any public domain and agency resources included in the guidebook.

TABLE OF CONTENTS
Forward ……………………………………………………………………………………………………….. p. 2
Section I: Using this Guide and Seeking Help……………………………………………………………….. p. 3
Inventory of Needs…………………………………………………………………………………...p. 4
Section II: Where to Start……………………………………………………………………………………...p. 5
VISN 8: VA Hospitals by Area…………………………………………………………...................p. 5
VA Outpatient Clinics and Community Based Outpatient Clinics (CBOC;s)……………………….p. 6-8
Health Care for Homeless Veterans Program (HCHV)………………………………………………p. 9-18
Veteran’s Health Administration Rehabilitation Programs.………………………………………….p. 19
Section III: Seeking and Accessing Federal Programs and Benefits…..……………………………………...p. 20
Eligibility/Benefits/Apportionment while incarcerated………………………….…….……………..p. 20-24
County Veterans Service Officers ……………………………………………………………………p. 25-31
Section IV: Finding a Job
Employment Services…………………………………………………………………………………p. 32
Additional Resources and Phone Numbers…………………………………………………………..…………p. 33-34
Forms Needed to File for VA Benefits…………………………………………………………………………p. 35-38

2

SECTION I: USING THIS GUIDE AND SEEKING HELP
This guide is for you to use while planning for your release and to keep as a reference after your
release. It includes addresses, phone numbers, and web sites that you can use to find out about
programs and resources in your area. You may want to ask a friend or family member to help you find
the information you need if you don't have phone or internet access. Keep in mind that this guide does
not include all of the services available. What is available in one area may be different from what is
available in another, so be sure to check with local resources to learn about services in your area.
While you are in prison, find out which unit in your facility can help you plan for your release (often
the education or transfer unit). Classes may be offered to help you improve your skills and prepare for
life after release.
If you need to write a letter to request information about a particular benefit or service, be clear. Keep
your letter short, to the point, and print or write clearly. Include the following information:
•

Your name and contact information.

•

A brief statement about your current situation.

•

Your specific request.

•

What you have done so far (Example: I have written to X organization and they suggested I contact
you).

•

Any restrictions for mailings (Example: Mail with staples/paper clips won’t be accepted by my
facility).

When contacting an agency for help by mail, email or phone, be persistent and polite in order to get the
best results. Ask questions if information is not clear to you. Remember that many organizations are
staffed by volunteers who are eager to help but may not have the answers you are looking for. If
someone cannot help you, ask them who can help and then have them connect you with that person.
The Internet is a great source of information about VA benefits and community resources in your area,
and this guide lists important web addresses near the back of the book. If computer access is not
available at your facility, you can visit the public library after release. Computer access may also be
provided at WorkSource and WorkSource Affiliate sites, WorkForce Development Council member
locations, and Employment Security Department offices (referred to as One Stop Career Centers). The
website for the Healthcare for Reentry Veterans (HCRV) Program is:
http://www1.va.gov/homeless/page.cfm?pg=38.
Begin thinking about what you will specifically need when you’re released. Ask yourself these kinds
of questions: Will I need housing? Will I need medical or mental health care, or substance abuse
treatment? Do I need to learn a job skill? Do I have any other legal issues, such as child support? How
do I restart my VA checks or Supplemental Security Income (SSI)?
Use the following Inventory of Needs to identify and organize your particular needs. You can refer
back to it and use it to track the steps you are taking to meet each of your identified needs.

3

Immediate Concerns

My plans to deal with these concerns:

Date of Release?
Probation—where, with whom?
Transportation
Housing
Clothing
Food
ID
Family contact ?
Work on getting support
Financial

My plan to deal with these concerns:

Employment
Disability/ Pension
Child Support/Alimony
Debt/ Credit Issues
Motor Vehicle fines
Voc Rehab/ School?
Health

My plan to deal with these concerns:

Medical Concerns/ Medication
Mental Health - Addictions - Recovery
Legal

My plan to deal with these concerns:

Traffic fines/Violations
Child Custody
Restitution
Anger Management
Domestic Violence
Probation/Parole Registering
Restrictions

4

SECTION II: WHERE TO START—MEDICAL CARE
To qualify for VA care you need:
A DD214… (a copy of your discharge papers).
An Honorable or General discharge
Served Active Duty.
After 9/9/1980, must have served at least 2 years active duty or any amount of time in Iraq or Afghanistan.

Your first step is to enroll in the VA System, there are several ways:
Visit: Any VA Medical Center (VAMC), Any Outpatient Clinic, Any Community Based Outpatient Clinic (CBOC)
Use the map on the COVER of this guidebook to locate the facility nearest you, addresses follow.
On the Internet go to www.va.gov.
Or Call the VA Health Benefits Service Center at 877-222-VETS , Mon-Fri, 8:00am-8:00pm EST for enrollment
assistance.
Contact information for all VA facilities in VISN 8 is listed below. You need a DD-214, VA form 10-10EZ
(Enrollment form), and the 1010 Supplement to enroll. Copies of these forms are in the back of this guidebook
or on the internet.

VA MEDICAL CENTERS/HOSPITALS
Area 1 – North Florida / South Georgia
VA Healthcare System
Malcolm Randall VAMC
1601 S.W. Archer Road
Gainesville, FL 32608-1197
Phone: 1-800-324-8387
Homeless Program: ext. 7461

Area 4 – Bay Pines VAMC
10000 Bay Pines Blvd.
Bay Pines, FL 33744
Phone: 727-398-6661 or 1-888-8200230
Mailing Address:
P.O. Box 5005
Bay Pines, FL 33744

Lake City VAMC
619 S. Marion Avenue
Lake City, FL 32025-5808
Phone: 1-800-308-8387

Area 5 – West Palm Beach VAMC
7305 N. Military Trail
West Palm Beach, FL 33410-6400
Phone: 1-800-972-8262
Area 6- Miami VAMC
1201 N.W. 16th Street
Miami, FL 33125
Phone: 1-888-276-1785

Area 2 – Orlando VAMC
5201 Raymond Street
Orlando, FL 32803
Phone: 1-800-922-7521

Area 3 – Tampa
James A. Haley VAMC
13000 Bruce B. Downs Blvd.
Tampa, FL 33612
Phone: 1-888-716-7787

Area 7- VA Caribbean Healthcare
System—Puerto Rico / US Virgin Islands
San Juan VAMC
10 Casia Street
San Juan, Puerto Rico 00921-3201
5

Area 7 Continued - Community Based
Clinic / Vet Center
District of St. Croix, RR2 Box 12
Kings Hill St. Croix VI 00850
Phone: 340-778-5553

Community Based Clinic / Vet Center
Havensight Mall Suite 304 & 310
Building III Upper Level St. Thomas,
U.S. Virgin Islands 00802
Phone:(340) 774-6674

VA OUTPATIENT CLINICS (OPC)
Facility

Address

Phone

Fort Myers OPC

3033 Winkler Extension, Fort Myers, FL 33916

239-939-3939

Jacksonville OPC

1833 Boulevard, Jacksonville, FL 32206

904-232-2751
or 877-870-5048

Mayaguez OPC

Avenida Hostos #345, Mayaguez, PR 00680-1507

787- 834-6900

New Port Richey OPC

9912 Little Road, New Port Richey, FL 34654

727-869-4100

Broward OPC

9800 W. Commercial Blvd., Sunrise FL 33351

(954) 475-5500

Ponce OPC

Paseo Del Veterano # 1010, Ponce, PR 00716-2001

787-812-3030

Tallahassee OPC

1607 St. James Ct., Tallahassee, FL 32308

850-878-0191
or 800-541-8387

Viera OPC

2900 Veterans Way, Viera, FL 32940

321-637-3788
877-878-8387

William V. Chappell, Jr.

551 National Health Care Drive, Daytona Beach,

VA OPC (Daytona Beach)

386-323-7500

FL 32114

VA COMMUNITY BASED OUTPATIENT CLINICS (CBOCS)
Facility
Arecibo CBOC

Address

Phone

Victor Rojas II / Zona Industrial Carr. 129

787-816-1818

Arecibo, PR 00612
Boca Raton CBOC

901 Meadows Rd., Boca Raton, FL 33433

561-416-8995

Brooksville CBOC

14540 Cortez Blvd., Ste. 108, Brooksville, FL 34613

352-597-8287

Coral Springs CBOC

9900 W. Sample Rd., Ste. 100, Coral Springs, FL 33065

954-575-4940

6

Deerfield Beach CBOC

2100 S.W. 10th Street, Deerfield Beach, FL 33442

954-570-5572

Delray Beach CBOC

4800 Linton Blvd., Building E, Ste. 300

561-495-1973

Delray Beach, FL 33445
Dunedin Primary Care

1721 Main Street, Dunedin, FL 34698

727-734-5276

Ellenton Primary Care

4333 US Hwy 301 North, Ellenton, FL 34222

941-721-0649

Fort Pierce CBOC

727 North US 1, Ft. Pierce, FL 34950

772-595-5150

Guayama CBOC

FISA Bldg. 1st fl, Paseo Del Pueblo, km 0.3, lote no 6,

787-866-8766

Guayama, PR 00784
Hollywood CBOC

3702 Washington St., Ste. 201, Hollywood, FL 33021

954-986-1811

Homestead CBOC

950 Krome Avenue, Ste. 401, Homestead, FL 33030

305-248-0874

Key Largo CBOC

105662 Overseas Highway, Key Largo, FL 33037

305-451-0164

Key West CBOC

1300 Douglas Circle, Bldg. L-15, Key West, FL 33040

305-293-4609

Kissimmee CBOC

2285 North Central Avenue, Kissimmee, FL 34741

407-518-5004

Lakeland CBOC

4237 South Pipkin Rd, Lakeland, FL 33811

863-701-2470

Lecanto CBOC

2804 W. Marc Knighton Ct., Ste. A, Lecanto, FL 34461

352-746-8000

Leesburg CBOC

711 W. Main Street, Leesburg, FL 34748

352-435-4000

Marianna CBOC

4970 Highway 90, Marianna, FL 32446

850-718-5620

Miami Outpatient Substance 1492 West Flagler St., Ste. 101, Miami, FL 33135

305-541-8435

Abuse Clinic (OSAC)
Naples Primary Care

2685 Horseshoe Drive, Ste. 101, Naples, FL 34104

239-659-9188

Ocala CBOC

1515 Silver Springs Blvd., Ocala, FL 34470

352-369-3320

Okeechobee CBOC

1201 N. Parrot Ave., Okeechobee, FL 34972

863-824-3232

Orange City CBOC

2583 South Volusia Ave. (17-92), Suite 300,

386-456-2080

Orange City, FL 32763
Pembroke

7369 W. Sheridan St., Ste. 102, Hollywood, FL 33024

954-894-1668

Pines / Hollywood CBOC
Port Charlotte Primary Care 4161 Tamiami Trail Unit 4, Port Charlotte, FL 33952
7

941-235-2710

Continued….VA COMMUNITY BASED OUTPATIENT CLINICS (CBOC’S)
Facility
St. Augustine CBOC

Address

Phone

1955 US 1 South, Ste. 200, St. Augustine, FL 32086

904-829-0814 or
866-401-8387

Saint Croix CBOC

Box 12, RR-02, The Village Mall #113

340-778-5553

Kings Hill, VI 00850-4701
St. Petersburg Primary

3420 8th Ave. South, St. Petersburg, FL 33711

727-322-1304

Havensight Mall, Bldg. III (Upper), Ste. 310

340-774-6674

Care Clinic
St. Thomas CBOC

St. Thomas, VI 00802
Sarasota Primary Care

5682 Bee Ridge Rd., Ste. 100, Sarasota, FL 34233

941-371-3349

Sebring Primary Care

3760 US Hwy 27 South, Sebring, FL 33870

863-471-6227

Stuart CBOC

3501 S.E. Willoughby Blvd., Stuart, FL 34997

772-288-0304

The Villages CBOC

Laurel Lake Professional Park, 1950 Laurel Manor Drive, 352-205-8900
Building 240, The Villages, FL

32162

Valdosta CBOC

2841 N. Patterson Street, Valdosta, GA 31602

229-293-0132

Vero Beach CBOC

372 17th Street, Vero Beach, FL 32960

772-299-4623

Zephyrhills CBOC

6937 Medical View Lane, Zephyrhills, FL 33541

813-780-2550

8

HEALTH CARE FOR HOMELESS VETERANS PROGRAMS - VISN 8
GAINESVILLE VAMC / LAKE CITY VAMC
Gainesville/Ocala Area Outreach
Case Manager: Dale Elzie, LCSW
Office hours by appointment, please call:
(352) 379-7461 or (800) 376-1611 x7461
Outreach at the following times/locations:
Tuesday: 11am-1pm St. Francis House
(352) 378-9079
413 S. Main St., Gainesville
Wednesday: 9am-11am

Salvation Army Ocala
320 NW 1st Avenue, Ocala

(352) 732-8326

Thursday: 3pm-4:30pm

Salvation Army Gainesville
(352) 376-1743
639 E. University Ave., Gainesville

Lake City/Valdosta Area Outreach

Case Manager: Ayanna Sampson, MSW
Office hours by appointment, please call: (386) 755-3016 or (800) 308-8387, ext. 3416
Outreach at the following times/locations:
Lake City:
Wednesday: 10:30am-12pm Catholic Charities Lake City
(386) 754-9180
258 Burke Ave., Lake City

2nd + 3rd Wednesdays: 3:00pm-4:00pm

By appointment only:
Georgia:
Tuesday: 9:00am-10:30am

Tuesday: 11:00am-1pm

Volunteers of America,
260 S. Marion Ave.,Ste. C-101,
Lake City, FL
Mayo Manna House
297 S.E. Pine St., Mayo

(386) 754-9926

(386) 294-2150

Georgia Dept. of Labor
221 S. Ashley Street, Valdosta

(229) 333-5211

New Horizon Day Center
714 Charleston, Valdosta, GA

(229) 242-5267

By appointment only: Veterans Services
378 State St., Waycross, GA
Cook County DFCS
1010 Hutchinson Ave., Adel, GA

(912) 285-6340

(229) 896-3672

Crossroads Gospel Rescue Mission (229) 985-7194
24 5th Street, Moultrie, GA

9

Jacksonville Area Outreach

Case Managers:
Office hours by appointment, please call:

Raul Patton, MSW - (904) 739-1872, ext. 202
Shawn Liu, LCSW - (904) 739-1872

Outreach at the following times/locations:
Monday: 10am-Noon St. John’s County St. Francis House
70 Washington St., St. Augustine, Fl

(904) 829-8937

Monday: 9am-10am
1st and 3rd Mondays

Baker County NE FL Community Action
84 W. Lowder St, MacClenny, FL

(904) 259-4481

Monday: 9am-10am
2nd and 4th Mondays

Salvation Army: Hope House
84 W. Lowder St, MacClenny, FL

(904) 321-0435

Monday: 5pm-7pm

Salvation Army
900 W. Adams Street, Jacksonville

(904) 356-8641

Tuesday 10am-Noon

Sulzbacher Center
611 E. Adams St., Jacksonville

(904) 359-0457

Tuesday: 2pm-4pm

Salvation Army Beach (by appt. only)
10900 Beach Blvd., Jacksonville

(904) 641-2122

Mission House
800 Shetter Ave, Jacksonville Beach

(904) 241-6767

Wednesday: 10am-12pm

Wednesday: 4:30pm-6:30pm Trinity Rescue Mission
622 W. Union St., Jacksonville

(904) 355-1205

Thursday: 9:30am-Noon Clara White Mission
613 W. Ashley St., Jacksonville

(904) 354-4162

Thursday: 9:30am-Noon

City Rescue Mission: New Life Inn
613 W. Ashley St., Jacksonville

(904) 421-5161

MHRC Quest
507 East Church Street, Jacksonville

(904) 358-2411

Friday: 9am-11:30am

Other Shelters/Resources in Jacksonville:
Circle of Love Ministries 13519 N. Main St., Jacksonville
Family Promise of Jacksonville PO Box 40363, Jacksonville
(Families with children)
SafeHouse of Jacksonville

3325-8 Plymouth St., Jacksonville

10

(904) 751-1034
(904) 354-1818

(904) 425-4228

Tallahassee Area Outreach

Case Manager: Denna Green-Corbett, MSW
Office hours by appointment, please call: (850) 521-5700 x1217 or (800) 330-1070 x1217
Outreach at the following times/locations:
Monday: 4:30pm-6pm Haven of Rest Rescue Mission
(850) 224-7313
510 West Tennessee Street,
Tallahassee, Florida 32301
Monday: 6pm-7pm

Tuesday: 1:00 -2:30pm

The Shelter
480 West Tennessee Street
Tallahassee, Florida 32301

(850) 224-8448

Day Services Center
(850) 224-9055
Bill Hanson Community Day Center
466 W. Tennessee St.

Tuesday 2:30 – 4:00 The Care Center
1224 Eppes Drive
Tallahassee, Florida
Tuesday (as needed) 4:30pm-6pm Hope Community
2729 West Pensacola Street
Tallahassee, Florida 32302
Wednesday: 10:30am-11:30am HomeFree Drop In Center
523 East Tennessee Street
Tallahassee, Florida 32301
Thursday (as needed) 4:30ish Georgia's State Benefits Office
101 S Broad St
Thomasville, GA 31792

11

(850) 597-8163

(850) 575-5566

(850) 222-7226

(229) 225-4405

ORLANDO VAMC
Orlando Area Outreach

Case Manager: Ken Mueller, LCSW
Office hours by appointment, please call: (321) 397-6609 or (800) 922-7521 x6609
Peer Support:
Lou Smith (321) 397-6610 x6610
or (800) 922-7521x 6610
Outreach at the following times/locations: Subject to change/call Ken Mueller first.
Monday 10:00am
Turning Point Drop- In Center
203 E. 3rd St. Sanford FL 32771
Tuesday 2:00pm

Orlando Rescue Mission
410 W. Central Blvd., Orlando FL 32805

Tuesday 9:00am

Daytona Homeless Access Center
330 North St., Daytona FL 32114

Wednesday 10:00am
(every other week)

Coalition for the Homeless
639 W. Central Blvd.Orlando FL 32801

Thursday 2:00pm

Salvation Army Men’s Lodge
624 Lexington Ave., Orlando FL 32801

Friday 10:00am

Osceola Christian Ministry Center
700 Union St., Kissimmee FL 34741

Other Shelters/Resources in Orlando Area:
Orlando Union Rescue Mission

Salvation Army of Orange County

Rescue Outreach Mission of Sanford

Women & Children’s Division
1525 W. Washington St., Orlando

(407) 422-4855

Women & Children’s Shelter
400 W. Colonial Drive, Orlando

(407) 423-8581

1701 W. 13th St., Sanford

(407) 321-8224

Brevard County Outreach Schedule
Office hours by appointment:

Case Managers: John Carroll, LCSW - (877) 878-8387 x2941
or (321) 637-3788 x2941
Ernest Duncklee, LCSW - (877) 878-8387 x2636
or (321) 637-3788 x2636

Tuesday 11:00am

Salvation Army (321) 269-3110 *** Area Shelter
1218 W. Main St. Titusville, Fl. 32769

12

Wednesday 2:30pm

CITA Mission

(321) 725-5160 *** Area Shelter

2330 Johnny Ellison Drive Melbourne, Fl. 32901
Thursday 9:00pm

East Coast Christian (Avenue Worship Center)
85 Richland Ave. Merritt Island, Fl. 32953

Thursday 11:15am

Central Brevard Sharing Center (321) 631-0306
113 Aurora Street Cocoa, Fl. 32922

Friday 10:00am

Daily Bread (321) 723-1060
815 East Fee Ave. Melbourne, Fl. 32901

As needed

North Brevard Charities (321) 269-6555
4475 South Hopkins Ave. Titusville, Fl. 32780

TAMPA VAMC
Tampa Area On-Call and Mobile Outreach Clinical Team

Chap Celerin:
(813) 781-5152
- office hours by appointment, please call:
Harry McCurdy:
(813) 610-5879
Health Care for Homeless Veterans Program:
10770 North 46th Street,
(813) 979-3556
Suite A-400, Tampa, FL 33617
Shelters in Tampa area:
Metropolitan Ministeries
(813) 209-1000
2002 North Florida Ave., Tampa
Salvation Army
610 West Waters Ave., Tampa

(813) 915-1004

Women’s Shelter - Salvation Army
Community Worship Center
1100 West Sligh Ave., Tampa

(813) 226-0055

BAY PINES VAMC
Daily Walk-in Clinic at Bay Pines Domiciliary: Staffed by HCHV Case Manager
Hours:
Address:

Mon-Fri (except holidays)
8am-11:30am - 1pm-3pm
Domiciliary - 10000 Bay Pines Blvd. VAMC Bay Pines, FL
Bay Pines Homeless Programs
(727) 398-6661 x 5986
(888) 820-0239 x 1263 x 4711
In Collier or Lee Counties--------------(239) 939-3939 x 6495

13

Shelters in greater St. Petersburg area:
Salvation Army Emergency Lodge
1400 4th Street South
St. Petersburg, FL
(727) 821-9123
Salvation Army Sarasota Corps
1400 10th St., Sarasota
(941) 954-4673
Salvation Army (not in st. Pete)
St. Vincent de Paul Shelter
401 15th Street North St.
Petersburg, Fla 33705
(727) 209-0249
Beacon House (Men only)
2151 Central Avenue St.
Petersburg, Fla 33713

(727) 823-5780

Salvation Army
1205 14h Street West
Bradenton FL

(941) 749-0925

People that Love Mission Inc.
817 5th Avenue N St.
Petersburg, Fla 33701
(727) 421-3745
Homeless Emergency Project
1120 North Betty Lane
Clearwater, Fla 33755
(727) 442-9041
Pinellas Hope
5726 126th Avenue North
Clearwater, Fla 33760

(727) 422-6540

Clearwater Homeless Intervention
Project Services (CHIPS)
1339 Park Street
Clearwater, Fla 34615
(727) 466-66

14

WEST PALM BEACH VAMC
W. Palm Area Outreach Case Managers:

Frank Babich, RPAOc
Gary Gallon, LCSW
Hank Rivera MSW

(561) 422-8223
(561) 422-8223
(561) 422-8223

Health Care for Homeless Veteran Program Outreach varies based on need. There is a drop-in
facility located on VA property in Building 6. The Veteran’s Resource Center is open Monday
through Friday 8am-12pm and 1pm-4:30pm. It is staffed by William Mickey, Homeless
Program Support Assistant. Ph: (561) 422-8223. The Center has available food (usually),
clothes, showers, laundry; it is located behind the West Palm Beach VAMC, 7305 North Military
Trail, W, Palm Beach, FL. Please call first.
Shelters/Resources in West Palm Beach area:
Salvation Army Center of Hope
Joshua House (men only)

1577 N. Military Trail, WPB

(561) 682-1118

2701 Broadway, WPB

(561) 712-8586
(561) 736-7006

MIAMI VAMC
Miami Area Outreach Schedules (subject to change):
Daily walk-in clinic:
HCHV offices at 1492 West Flagler, Miami, FL
(305) 541-5864
Hours:
Monday - Friday 8am-12noon (except holidays)
Outreach Case Manager: Rodly St. Villien: (305) 541-5864 x 131
Broward County: Monday
9am-12pm
Homeless Assistance Center (HAC) South
Tuesday
9am-12pm
Cooperative Feeding
Wednesday
9am-12pm
Jubilee Center
Friday
9am-12pm
St. Laurence Chapel
Dade County:

1st and 3rd Weds

9am-12pm

2nd and 4th Weds

9am-2pm

Thursday

9am-12pm

1st and 3rd Friday

9am-2pm

Miami Homeless Assistance Center (HAC)
1550 N. Miami Ave., Miami FL
Homestead HAC shelter
28205 S.W. 125th Ave., Homestead FL
Miami Salvation Army
1907 NW 38th St., Miami, FL
Miami Beach Outreach, in the community

Miami Shelters/Resources:
If homeless within Miami city limits, contact the City of Miami Outreach
Team 305-576-9900 within 48 hours of their release for a shelter bed.
City team meets w/vet and refers to Community Partnership Homeless
Assistance Center (HAC).
North HAC: (305) 329-3000
South HAC: (305) 416-7143
Miami cont….

726 NW 1st Ave., Miami
1907 NW 38th St., Miami

Camillus House Shelter
Salvation Army
Miami Rescue Mission

15

305-374-1065
305-637-6720

for Women and Children

2250 NW 1st Ave., Miami

305-571-2250

Monroe County: (Key West) Outreach Case manager Susan Spiegel, LCSW (305) 293-4609 x 1374
VA Clinic (connected to the Naval Outpatient Clinic)
1300 Douglas Circle, Key West, FL
Shelter: KOTS (Keys Overnight Temporary Shelter) on Stock Island will direct to
Soup kitchen and clinic, etc. No phone number: Referrals and information are
available from local/community based programs.

PUERTO RICO / US VIRGIN ISLANDS---SAN JUAN VAMC (VA CARRIBEAN)
Puerto Rico Area Outreach Information:
Contact HCHV Program Coordinator Daniel Aponte Ramos: 787-641-7582, ext. 12327
Health Care for Homeless Veterans Program—Puerto Rico
Puerto Rico VAMC
10 Casia Street, San Juan, PR 009210-3201

US Virgin Islands - Health Care for Homeless Veterans Program
Contact the following sites for specific information on HCHV outreach schedules:
Community Based Clinic/Vet Center
District of St. Croix
RR2 Box 12, Kingshill
St. Croix, VI 00850
(340) 778-5553

Community Based Clinic/Vet Center
District of St. Thomas/ St. John
9800 Buccaneer Mall, Suite 8
Charlotte Amalie
St. Thomas, VI 00802
(340) 774-6674

16

HOMELESS VETERANS PROGRAMS IN SURROUNDING AREAS

VISN 16

PENSACOLA
Outreach Case Manager: Scott Turner, MSW
VA Outpatient Clinic
312 Kenmore Road, Pensacola, Fl 32503
1-800-897-8977, ext. 7714
850-471-7714 or cell # 850-723-3900
Pensacola Shelter:

The Waterfront Rescue Mission
16 W. Main St.
Pensacola, FL 32594
850-438-4027

VISN 7:

ALABAMA

Homeless Veterans Program/Psychiatry/116
VA Medical Center
700 S. 19th Street
Birmingham, Alabama 35233
(866) 847-4243, ext. 6751 or (205) 933-8101, ext. 6751

This is first place for homeless veterans to go to become eligible for services; look
for the Homeless Program on the 7th floor of the VAMC, 8am-4:30pm, Mon-Fri.
GEORGIA

Health Care for Homeless Veterans Program
Atlanta VAMC/122
1670 Clairmont Road
Decatur, GA 30033
(800) 944-9726, ext. 7436 or (404) 321-6111, ext. 7436
This number will give you the on-call worker for the day.
VA Medical Center/122U
1 Freedom Way
Augusta, GA 30904
(800) 836-5561, ext. 7617 or (706) 733-0188, ext. 7617

17

GEORGIA, cont’d.

Metro Atlanta Task Force for the Homeless : Walk-ins welcome. The
Taskforce is the clearinghouse for shelters and transitional housing for all
of metro Atlanta. It is the best and only place to call or visit to find out
which shelters have vacancies at any given time.
477 Peachtree St.
Atlanta, GA 30308
1-800-448-0636 or (404) 230-5000
Augusta Task Force for the Homeless, Inc.
730 East Boundary Street
Augusta, GA 30901
1-866-256-7021 (homeless emergency hotline) / 706-723-0040

SOUTH CAROLINA

Health Care for Homeless Veterans Program
VA Medical Center
109 Bee Street
Charleston, South Carolina 29401
(888) 878-6884 or (843) 789-7953
Linda Williams is the Coordinator. There is a walk-in clinic on the 3rd floor of the
Medical Center, in Mental Health, where there are screenings from 9am-11am,
Mon-Fri.
VA Medical Center/116
6439 Garners Ferry Road
Columbia, South Carolina 29209
(800) 293-8262, ext. 5818 or (803) 776-4000, ext. 5818
Ms. Rebecca Barnette is the Program Manager, ext. 7695
(800) 784-8381, ext. 4188 or (804) 675-5000, ext. 4188 for Carol Murray

18

VETERANS HEALTH ADMINISTRATION PROGRAMS
Health Care for Homeless Veterans Programs. Every VA Medical Center has a Health Care for Homeless Veterans
(HCHV) Program which helps connect homeless veterans with health care and services at the VA and agencies in their
local community. The HCHV program has outreach workers who meet with veterans at various locations in the
community. Workers can make referrals for medical and mental health care, and offer case management to help veterans
access transitional housing assistance and linkage to permanent housing. VA has no emergency housing for veterans.
Eligible veterans receive assistance in pursuing SSI/SSDI benefits, as well as VA benefits and entry into other VA
programs.
Primary Care, Mental Health Care , and Substance Abuse Treatment.
We strongly encourage all eligible
veterans to enroll in our primary care clinics and to speak to health care providers about any health concerns they have,
including those that may require specialty care services. There are both residential and outpatient services available for
veterans in need of substance abuse treatment. We strongly recommend that veterans who want substance abuse treatment
talk to a VA health care professional as soon as possible.
Post Traumatic Stress Disorder.
There are both residential and outpatient services available for veterans with Post
Traumatic Stress Disorder (PTSD). The residential PTSD services offer an intensive therapeutic experience in a structured
environment. Some of our facilities offer treatment for noncombat related PTSD and specialized programming for women
veterans with PTSD.
Vocational Rehabilitation and Employment. These programs provide assistance with resumes, job leads in the
community, vocational training and help dealing with other barriers that may make it hard for veterans to get a job.
Veterans Industries and Compensated Work Therapy (CWT) Programs.
CWT offers structured work
opportunities and supervised therapeutic housing for at-risk and homeless veterans with physical, mental health, and
addictions problems. Veterans are paid for their work and receive ongoing supportive case management which helps
them maintain successful employment.
Grant and Per Diem Transitional Housing. The VA partners with community agencies to provide transitional
housing to homeless veterans. Veterans pay up to 30% of their income monthly and can reside in this housing for up to
two years, provided they participate in appropriate health care treatment and actively plan for fully independent
community living. Admission criteria for these programs varies throughout the state. Talk with your local HCHV
Program representative for more information about these housing options.
Domiciliaries. These are short-term residential programs that provide veterans with a host of rehabilitation services.
Workshops focus on skill building, and individual and group counseling are offered. There is an emphasis on relapse
prevention and veterans are encouraged to develop skills they can use to lead productive, independent lives.
VA Supported Housing. HUDVASH The HUD VASH program is a partnership between HUD and VA. HUD assists
with housing costs, and VA provides case management. The veteran must participate in case management to maintain
eligibility for VASH. The maximum income allowed for a one person household is approximately $18,750 per year. The
veteran pays approximately 30% of his/her income towards their rent, and HUD pays the remainder. The veteran is
responsible for security and utility deposits, and also pays regularly occurring household expenses such as rent obligation,
utilities, etc.
After the veteran is admitted into VASH program, the local housing authorities determine voucher eligibility based upon
HUD criteria. Veteran is able to live in housing of their choosing, but the landlord must accept the Housing Choice
Vouchers for Veterans. The veteran signs a lease and is responsible for the obligations of the legal document. Veterans
can stay in the program for up to 5 years.

19

SECTION III: SEEKING AND ACCESSING FEDERAL PROGRAMS AND BENEFITS
(Pension Claims—Non-Service Connected—Service Connected—Compensation & Pension)
U.S. Department of Veterans Affairs—Regional Office, St. Petersburg, Florida
The Department of Veterans Affairs publishes a booklet called “Federal Benefits for Veterans and Their
Dependents” that describes the type of benefits available and lists the addresses and phone numbers for
VA facilities nationwide. Write the VA Regional Office (VARO) below to request a copy.
VA Regional Office
9500 Bay Pines Blvd.
St. Petersburg, FL 33708

Phone: 1-800-827-1000

Florida Department of Veterans Affairs (FDVA) provides assistance with Veterans benefits and entitlements
information, VA claims process, representation and advocacy, trauma counseling, Veterans Homes for those
in need of nursing care, and employment assistance through federally funded reintegration projects.
Contact:
Florida Department of Veterans Affairs
Mary Grizzle Building, Rm. 311-K
11351 Ulmerton Road, Largo, Fl. 33778-1630
Phone: (727) 518-3202 Fax: (727) 518-3216
Georgia Department of Veterans Service: For information call (800) 827-1000
Central Office
Floyd Veterans Memorial Building
Suite E-970
Atlanta, GA 30334
Phone: (404) 656-2300
Puerto Rico Public Advocate for Veterans Affairs
Mercantil Plaza Bldg.

Mailing Address:

Fourth Floor, Suite 4021

P.O. Box 11737

Hato Rey, PR 00918-1625

Fernandez Juncos Station

Ph: (787) 758-5760 Fax: (787) 758-5788

San Juan, PR 00910-1737

Virgin Islands Office of Veterans Affairs:
1013 Estate Richmond
Christiansted, St. Croix VI 00820-4349
Ph: (340) 773-6663 Fax: (340) 692-9563

20

ELIGIBILITY FOR VA BENEFITS DURING INCARCERATION
Veterans incarcerated and incarcerated dependents may apply for the same compensation,
dependency and indemnity compensation (DIC) – service connected death benefits – and pension
benefits as veterans who are not incarcerated. However, Congress restricts the amount of benefits
that may be paid to a veteran or dependent while he or she is incarcerated. These benefits are
institutionalized as part of law: 38 U.S.C Sec 5313 (a), 38 C.F.R., Sec. 3.665 (a), (d), which reads
as follows:
If a veteran is incarcerated as the result of a “felony” conviction as defined by law: “Any
offense punishable by death or imprisonment for a term exceeding one year, unless
specifically categorized as a misdemeanor under the law of the prosecuting jurisdiction.”
Then, the amount paid to a veteran incarcerated for a service-connected disability is
generally limited by law to the 10 percent disability rate, or half the amount of the ten
percent rate if the veteran’s disability rating is 10 percent. (If the veteran is rated before
incarceration as 20 percent disabled or higher, he will receive only the amount payable to
a 10 percent disabled veteran.) Incarcerated DIC recipients will receive one-half the
amount paid to a veteran receiving compensation payments for a 10 percent-rated
disability.
A veteran may not receive non-service connected VA pension benefits, or any portion of
these benefits, while incarcerated for a felony or misdemeanor. However, his family may
receive an apportionment of such benefits under the procedure described above. (See 38
C.F.R. Sec.3.666)
One important requirement for eligibility for VA benefits is that the veteran has to have been
issued either an honorable or general discharge, or would have received one if not for reenlisting. If a veteran had two periods of service, one honorable and the other less than
honorable, he may still be eligible for VA benefits based on the honorable period of service.
VA Medical Care can not be provided to veterans in prison, but VA health facilities may provide
care to you after your release. Contact 1-877-222-8387 to find the medical center nearest you.
Benefits Payments While Incarcerated
There is a 60-day "grace period" following a conviction when you may still receive full benefits.
To avoid an overpayment, it is important that you notify the VARO immediately when you go to
prison if you are receiving payments. If you do not notify the VA and receive overpayment, you
and your family will lose all financial payments until the debt is paid.
For example, Joe is a veteran who receives a VA pension. He commits a crime, is convicted, and
is incarcerated, but doesn't tell the VA right away and keeps getting paid for 6 months. After
serving his sentence of 18 months, he is released and applies to the VA to have his pension
restarted. He will have an overpayment which must be recovered from the restarted benefits.
Until the overpayment is recovered, Joe will have to go without that income.
21

Your award for compensation or pension benefits should resume from the date you are released,
as long as the VA receives notice of release within one year. Form 21-4193, Notice to
Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution,
available through your counselors should be completed before release, signed by a prison official
and submitted to VA Benefits Administration.
Apportionment
Although legally, the veteran can only receive a portion of the full amount payable for his or her
disability rating, the remaining balance may be “apportioned to the individual’s dependent
family”. To apply for apportionment, the veteran must send a letter that identifies the veteran and
the apportionment claimant and makes it clear they are requesting an apportionment of his VA
benefits to the VA Regional Office (VARO) that has jurisdiction over the veteran’s case. VA
regulations clearly specify this apportionment amount will only go to family members if they can
show financial need for such amount. This applies to the spouse, children, or dependent parents
who are involved in the application.
In deciding whether any apportionment is appropriate, the amount of the apportionment, and to
whom it will go, the following factors are considered:
• The family member’s income and living expenses;
• The amount of compensation available to be apportioned;
• The needs and living expenses of other family members; and
• Special needs of any of the family members.

For example: a veteran incarcerated rated as 80 percent disability can only receive the amount
he or she would get if he or she were 10 percent disabled. However, his or her family may be
apportioned up to 70 percent, the difference of the 80 percent rating. (DIC may also be
apportioned with similar restrictions.)

22

There is a 60-day “grace period” following conviction where the veteran, or Dependency or
Indemnity Compensation (DIC) recipient, may still receive full benefits. If the veteran continues
to receive benefits after the 60-day period, it will result in an “overpayment”. The VA considers
it to be the recipient’s responsibility and fault if this occurs because the recipient failed to notify
the VA of his or her incarceration. Attempts to obtain a waiver in these situations of
overpayment are often unsuccessful. As a rule, the veteran loses most, if not all, financial
benefits until the VA recovers the entire overpayment. It has also been a standard procedure that
the family will not be entitled to receive an apportionment until the debt is completely recovered.
For more information concerning VA debt collection rules that may affect the veteran
incarcerated, telephone: 1-800-827-1000 and request a Veterans Service Organization
representative or, write to a Veterans Service Organization.
One other relevant restriction on veteran’s incarcerated eligibility for service connected disability
compensation is that: “No total disability rating based on un-employability, may be assigned to
an incarcerated veteran”.
It is important to remember that most VA decisions, including those on apportionment, can be
appealed to the Board of Veterans Appeals and, if need be, to the Court of Appeal for Veterans
Affairs.
Re-starting Benefits at Release
It is important that each disabled veteran receiving compensation or DIC payments promptly
notify the VARO. Regular full benefit payments should begin upon release, providing the VA is
notified of the veteran’s release, including placement within a community treatment center or
halfway house in the community, within one year of release. VARO needs formal notification
from the prison of your release in order to re-start benefits: The sooner that document is
provided to VARO, the sooner VARO can begin to process your request.
Seeking Help After Release
If you would like to get benefits or think you have a pending claim before the VA, it is best to
get professional help to assist you.
Many Veterans Service Organizations (VSOs) have trained staff who can help you with your VA
claim, and can legally represent your claim before the VA. Some also help homeless and at-risk
veterans find the support services they need. You can contact any VSO listed in the Guidebook
to learn an office near you.
Seeking Benefits On Your Own
Although we encourage you to seek the aid of a service representative, you may choose to apply
for VA benefits on your own. Write your local VA Regional Office or find the forms online at:
www.vba.va.gov/pubs/forms1.htm. You can also apply for certain benefits online at:
http://vabenefits.vba.va.gov/vonapp/main.asp.

23

Below are brief descriptions of forms needed to file for certain VA benefits. Be sure you use a
return address where mail will get to you as quickly as possible. Make photocopies of all forms
for your records before sending your packet to the VARO nearest you.

•

VA Form 21-526 - Application for Compensation or Pension- must be filed to apply for
compensation or pension. Mail your DD-214 and the following forms to the VARO nearest
your release destination 30 to 45 days before your release.

•

VA Form 21-4138 - Statement in Support of Claim - lets you explain why you deserve the
benefits you are asking for because of your disability or disorder. It is best to have an
experienced service representative help you complete the form.

•

VA Form 21-4142 - Authorization for Release of Information - If you have received medical
or mental health care, that may be relevant to your claim, from anyone other than a VA
Medical Facility, you need to fill out a VAF 21-4142 giving permission for release of
medical records to the VA.

•

VA Form 10-10EZ - Enrollment for Medical Benefits - is used by the VA to determine if you
can receive medical benefits. Complete the form and bring it with you to the VA medical
facility where you will seek evaluation for treatment.

•

VA Form 28-1900 - Vocational Rehabilitation for Disabled Veterans - is needed to apply for
the vocational rehabilitation program to help veterans who were disabled during their service
reach maximum independence in daily living, to learn the skills needed to get a job, and to
find and keep a job. Send Form 28-1900 to the VARO in your area 10 to 15 days before your
release.

•

VA Form 70-3288 - Request for and Consent to Release of Information from Claimant's
Records - is used to get records relevant to your claim from VA facilities (regional offices,
medical centers, outpatient clinics, and vet centers). Request a fee waiver under section 38
C.F.R. Sec.1.526 (h), which requires the VARO to provide a veteran with one set of his or
her records free of charge.

24

County Veteran Service Officers
County Veteran Service Officers (VSO’s) are a good first link to helping you access VA Benefits, file claims,
restart pensions, etc. Located in counties throughout the State, these men and women work with veterans and
their families to explain the process of applying for benefits from the VA. List Revised July 2008.

BROWARD

ALACHUA
James W. Lynch, Director
218 SE 24th St., Gainesville, FL 32641
Phone: (352) 264-6740 Fax: (352) 264-6703
E mail: JLynch@alachuacounty.us

Floyd D. White, Manager, CVSO, Room 200
Email: fwhite@broward.org
Ivy Martin, VSO
1600 W. Hillsboro Blvd., Room 150 Deerfield Beach,
FL 33442
Phone: (954) 831-1230
Fax: (954) 831-1244 E mail: imartin@broward.org

BAKER
Herbert O. Hicks, Director
(Mon., Tues., Wed. & Thur)
55 N. 3rd Street A-6 Center Office
MacClenney, FL 32063
Phone: (904) 259-2516
Fax: (904) 259-7610 or 259-9034
E mail: vet@bakercountyfl.org

Owen Walker, VSO Customer Relations Unit
Kenneth Morris, VSO
2995 N. Dixie Highway
Ft. Lauderdale, FL 33334
Phone: (954) 537-2936, Fax: (954) 537-2914
E mail: owalker@broward.org

BAY
Ray Carroll, CVSO Director
647 Jenks Ave.
Panama City, FL 32401
Phone: (850) 784-4044/4078
Fax: (850) 784-6181

Ivy Martin, VSO
3550 Hollywood Blvd, Rm 190
Hollywood, FL 33021
Phone: (954) 831-0420, Fax: (954) 831-0422
E mail: imartin@broward.org

BRADFORD
(Tue. and Thurs. only, 8-5)

Marie Lerouge, VSO
10077 NW 29th Street
Coral Springs, FL 33065
Phone: (954) 761-2125 Fax: (954) 341-3918
E mail: mlerouge@broward.org

Nathan Hines
Bradford County Courthouse
PO Drawer B, Starke, FL 32091
Ph: (904) 966-6385 or 1-800-280-9262
Fax: (904) 966-6386

Jonnett Simms, VSO
501 NW 103rd Avenue
Pembroke Pines, FL 33028
Phone: (954) 538-6955, Fax (954) 538-6959
E mail: jsimms@broward.org

BREVARD
Glenn A. McGuffie
2725 Judge Fran Jamieson Way,
Viera, FL 32940
Phone: (321) 633-2012
Fax: (321) 637-5432
E mail: glenn.mcguffie@brevardcounty.us

Vito Rao, VSO
5000 Nob Hill Rd.
Sunrise, FL 33351
Phone: (954) 749-2550, Fax: (954) 749-2551
E mail: vrao@broward.org

25

CALHOUN
Tammy Rushing
Calhoun County Courthouse (Tues & Wed 8am-4pm)
20859 S.E. Central Ave., E .Room 4
Blountstown, FL 32424
Phone: (850) 674-8305
Fax: Use office #; call ahead to fax
E mail: CalhounVSO@gtcom.net

DESOTO
Paul M. Erickson
201 E. Oak Street, Suite #202
Arcadia, FL 34266
Phone: (863) 993-4858, Fax: (863) 993-4857
E mail: p.erickson@co.desoto.fl.us
DIXIE
Jerry Prater (Tue., Wed., & Thurs. only, 8:00am 5:00pm) 405 SE 22nd Ave.
mail: PO Box 1119, Cross City, FL 32628
Phone: (352) 498-1246, Fax: (352) 498-1286
E mail: dixievet@inetw2.net

CHARLOTTE
James A. Barrett, Director
2280 Aaron St., Cultural Center
Port Charlotte, FL 33952
Phone: (941) 625-4422 Fax: (941) 625-0561
E mail: James.Barrett@charlottefl.com

DUVAL
Herschel Allen, VSO Supervisor/CVSO
117 West Duval St # 175, Jacksonville, FL 32202
Phone: (904) 630-3680 Fax: (904) 630-3422
E mail: hallen@coj.net

CITRUS
John J. Kenney – CSO
2804 W. Marc Knighton Ct.-Suite B140
Lecanto, FL 34461-8334
Phone: (352) 527-5915 Fax: (352) 527-5916
E mail: john.kenney@bocc.citrus.fl.us

ESCAMBIA
*DAV Contracted Operation
(Monday-Wednesday, 8:00am-4:30pm)
Jerry White
312 Kenmore Road
Pensacola, FL 32503
Phone: (850) 471-7754)
(No email)

CLAY
Madelyn Proctor, CVSO
2471 Highway 16 West (PO Box 1366)
Green Cove Springs, Fl 32043
Phone: (904) 269-6326 Fax: (904) 278-4717
E mail: Madelyn.Proctor@co.clay.fl.us
COLLIER
Peter P. Kraley, Director
Collier County Government Center,
3301 Tamiami Trail E. Bldg. H , Suite 212
Naples, FL 34112
Phone: (239) 774-8448 Fax: (239) 774-1667
E mail: veteranservices@colliergov.net

FLAGLER
Salvatore Rutigliano VSO
1769 E. Moody Blvd, Bldg 2, Suite 108
Bunnell, FL 32110
Ph: (386) 313-4014 Fax: (386) 313-4114
E mail: srutigliano@flaglercounty.org
FRANKLIN
William E. Scott
(Mon, Tue, Wed, & Fri ONLY—8:30am – 4:30pm)
Franklin County Courthouse
Apalachicola, FL 32320
Office: (850) 653-8096 Fax: (850) 653-4139
E mail: franklinvets@gtcom.net

COLUMBIA
Robert (Bob) Little, CVSO
264 NE Hernando Ave. Suite 101
Lake City, FL 32055
Phone: (386) 758-1013/1012
Fax: (386) 758-2184
E mail: robert_little@columbiacountyfla.com or
susan_melton@columbiacountyfla.com

GADSDEN

Wess Hinson

DADE
Edward C. Van Loan, Jr.
150 NW 79th Street, Room 503
Miami, FL 33150
Phone: (305) 795-1511 Fax: (305) 795-1542
E mail: dadevet@aol.com

5-B East Jefferson Street
Mail: PO Box 1799, Quincy, FL 32351-5799
Ph: (850) 875-8661, Fax: (850) 875-8792
Email: jjordan@gadsdengov.net

26

GILCHRIST
Major L. Stroupe, CVSO
Mon thru Thur 8:30am – 4:30pm
105 NE 1st Street Trenton, FL 32693
Phone and fax: (352) 463-3188 or (800) 236-1739
E mail: cvso@gilchrist.fl.us

HERNANDO
Matt Peters, Veteran Services Manager
Airport Industrial Park
16110 Aviation Loop Drive
Brooksville, FL 34604-6803
Ph: (352) 754-4033 Fax: (352) 754-4094
E mail: MPeters@co.hernando.fl.us

GLADES
Jim Herrington, CVSO
PO Box 1018
Moore Haven, FL 33471-1018
Thurs. only, 7:30am-4:30pm
Ph: (863) 946-1281, fax: (863) 946-2860
E mail: jherrington@myglades.com

HIGHLANDS
Joseph Dionne, CVSO
Office: 7205 S. George Blvd
Mail: PO Box 1926, Sebring, FL 33871-1926
Phone: (863) 402-6623 Fax: (863) 402-6796
E mail: jdionne@hcbcc.org

GULF
James (Jim) C. Kennedy
1000 Cecil G. Costin Sr. Blvd.
Port St. Joe, FL 32456-1647
Monday Phone: (850) 639-3019
Tuesday-Friday Phone: (850) 229-6125 Fax: (850) 2297180
E mail: vsgulfco@gtcom.net

HILLSBOROUGH

John Colbert
1101 E. 139th Ave ,Tampa, FL 33613
Ph:(813) 975-2181 Fax: (813) 975-2187
E mail: stromf@hillsboroughcounty.org
201 14th Avenue SE, Ruskin 2nd Tues.
By appoint: Noon - 4:30 pm

HAMILTON
Herbert Lumpkin, VSO
1153 US Hwy 41, Suite 4
Jasper, FL 32052
Ph: (386) 792-1272 Fax: (386) 792-6896
E mail: veteranserviceoffice@alltel.net

East Tampa Veterans Memorial Museum & Park
3602 N Highway 301, Tampa, 33619
(813) 744-5588 Tues only: 8:00am – 4:30pm
3402 N. 22nd St. (Thurs.) 8:00am – Noon
2103 N. Rome Ave. (Wed.) 8:00am - Noon
307 N. Michigan Ave., Plant City 33563
Thursday Only: 8:00am - NOON

HARDEE
Larry Pelton (Tues / Thurs ONLY)
307 N. 6th Avenue
Wauchula, FL 33873-2319
Ph: (863) 773-9853 Fax: (863) 773-3827
E mail: 2bowlers@embarqmail.com

Reggie Washington, Homeless Recovery
2410 N. Tampa St., Tampa, 33602
Mon-Tue, 7:00am—5:30pm
Ph: (813) 276-2976 / (813) 307-4717
Fax: (813) 276-2047

HENDRY
Richard Marquith CVSO (Mon, Wed, Fri)
Courthouse Square
165 S. Lee Street, Labelle
Ph: (863) 675-5250
Fax: (863) 675-5317

HOLMES
Joey Marsh (Mon - Thurs (8:00am-4:00pm)
812-B S. Waukesha Street
Bonifay, FL 32425
Ph: (850) 547-2897 Fax: (850) 547-9252
E mail: vetsrmyjob@earthlink.net

(Tues & Thur)
100 E. El Paso Avenue, Clewiston
Phone: (863) 983-1491

INDIAN RIVER
Joel V. Herman, Manager
Office: 2525 St. Lucie Avenue Vero Beach, 32960
Mailing Address: 1800 27th St., Vero Beach, 32960
(8:30am-12:00pm, 1:00pm-5:00pm)
Ph: (772) 567-8000, Ext. 1499 Fax: (772) 770-5038
E mail: jherman@ircgov.com

Mail: PO Box 2340
Labelle, FL 33975-2340 E mail:
rmarquith@hendryfla.net
27

INDIAN RIVER
Sebastian Square Mall
Rebecca L. Mitchell, Assistant
11602 U.S. Hwy # 1 Sebastian, FL 32958
(8:30am-12:00pm, 1:00pm-5:00pm)
Ph: (772) 589-6597 Fax: (772) 581-4988
Email: bmitchell@ircgov.com

LEVY
Michael Engel, Veteran Service Officer
Office: 353 South Court St.
Mail: PO Box 310, Bronson, FL 32621
Phone: (352) 486-5210 or (800) 733-5389
Fax: (352) 486-3329
E mail: levyvets@yahoo.com

JACKSON
John H. F. Turner, Jr., CVSO
2851 Jefferson Street
Marianna, FL 32448
Ph:(850)718-0003/4 Fax: (850) 482-9987
E mail: turner_jcvso@embarqmail.com

LIBERTY
John B. Eubanks
PO Box 454, Bristol, FL 32321
Ph: (850) 643-5960, Fax: (850) 643-3334
E mail: jbe@gtcom.net
MADISON
Oliver J. Bradley
Office: County Courthouse Annex-Room 215 Mail: PO
Box 237, Madison, FL 32341
Ph: (850) 973-3208; Fax: (850) 973-2923
E mail: mad.covets@hotmail.com

JEFFERSON
Carol Ellerbe
PO Box 45, Monticello, FL 32345
Ph:(850) 342-0211 Fax:(850) 342-0214
E mail: carolellerbe@embarqmail.com
LAFAYETTE
Carlton Black, Manager (Wednesday Only)
LaFayette County Courthouse
PO Box 294, Mayo, FL 32066
Phone: (386) 294-5010; Fax: (386) 294-4231
E mail: lafvso@windstream.net

MANATEE
Harold “Hal” Willis, Jr., CSO
Office: Manatee County Government Center
1112 Manatee Ave. W., #300
Mail: PO Box 1000, Bradenton, FL 34206
Ph: (941) 749-3030 Fax: (941) 745-3796
E mail: hal.willis@mymanatee.org

LAKE
Tom Osebold, CVSO
Office: 1300 Duncan Dr., Bldg. B
Mail: PO Box 7800 Tavares, FL 32778-7800
Phone: (352) 742-6585/ Fax: (352) 742-6588
E mail: TOsebold@lakecountyfl.gov

MARION
Jeffrey Askew, Director
Daisy Diaz, Veterans Services Supervisor
2528 E. Silver Springs Blvd., Ocala FL 34470-7010
Ph: (352) 671-8422/23 Fax: (352) 671-8424
E mail: Jeffrey.Askew@marioncountyfl.org

LEE
John Ebling, Director
2072 Victoria Ave., Ft. Myers FL 33901
Mailing Address: PO Box 398, Ft Myers, FL 33902
Ph: (239) 938-1100, Fax: (239) 938-1101
E mail: leo911@aol.com

MARTIN
John L. Haddox, CSO
2401 SE Monterey Road
Stuart, FL 34996
Ph: (772) 288-5448 Fax: (772) 221-2312
E mail: jhaddox@martin.fl.us

LEON
Mattie Carney
Office: 918 Railroad Avenue, Tallahassee, 32310
Mail: Leon County Courthouse
301 S. Monroe St., Tallahassee, FL 32301
Ph: (850) 606-1940 Fax: (850) 606-1941
E mail: KeenD@leoncountyfl.gov

MONROE
Charles L. Ingraham, Director/ CSO
Harvey Government Center
1200 Truman Blvd. # 204, Key West, FL 33040
Ph: (305) 295-5150 Fax: (305) 295-5175
E mail: Ingraham-Charles@monroecounty-fl.gov

28

Robert Day, Veterans Counselor
1111 N. Rock Springs Rd., Apopka, FL 32712
Ph: (407) 654-1055 Fax: (407) 654-1056
Tuesday only—8:00am-4:00pm

Peggy Ricciuto, Counselor
490 63rd Street (Ocean), Ste. 100
Marathon, FL 33050
Phone: (305) 289-6009
E mail: Ricciuto-Peggy@monroecounty-fl.gov
E mail: Johnson-Gary@monroecounty-fl.gov

1701 Adair St., Ocoee, FL 34761
Ph: (407) 654-8493 Fax: (407) 654-8493
Mon and Thurs only—8:00am-4:00pm

Gary E. Johnson, Admin. Vet Services
88820 Overseas Highway, Tavernier, FL 33070
Ph: (305) 852-7104 Fax: (305) 853-7304

OSCEOLA

Julio C. Cruz

E mail: Johnson-Gary@monroecounty-fl.gov

108 Park Place Blvd., Bldg. C
Kissimmee, FL 34741
Ph: (407) 742-8400 Fax: (407) 742-8434
E mail: tmal3@osceola.org
Wednesday only:
1322 10th St
St. Cloud, FL 34769
Ph: (407) 742-8555

NASSAU
John Martin
Mon-Thurs: 8:30am-4:00pm, Fri 8:30am-12:30pm
76347 Veteran’s Way, Yulee, FL 32097
Ph: (904) 548-4670 Fax: (904) 548-4539
E mail: jmartin@nassauclerk.com
OKALOOSA
Beatrice Love-Moore, Director
601-A N. Pearl Street, Suite 100
Crestview, FL 32536
Mon-Fri. 8:00am-Noon, 1:00pm-5:00pm
Ph: (850) 689-5922 Fax: (850) 689-5566
E mail: blovemoore@co.okaloosa.fl.us

PALM BEACH
Craig Carr
810 Datura St. (Mail: PO Box 1989)
West Palm Beach, FL 33401-5211
Ph: (561) 355-4761 Fax: (561) 355-4801
E mail: ccarr@co.palm-beach.fl.us

Gail Hull, Veterans Counselor
Okaloosa County Courthouse Annex
6 11th Ave., Suite G-3, Shalimar, FL 32579
Mon-Fri: 8:00am-Noon, 1:00pm-5:00pm
Ph: (850) 651-7258, Fax: (850) 651-7742

PASCO
Bill Klinger, Supervisor
8620 Galen Wilson Blvd., Port Richey, FL 34668
Ph: (727) 834-3282 Fax: (727) 834-3339
E mail: wklinger@pascocountyfl.net

OKEECHOBEE
Elizabeth “Betsy” Grinslade
462 Highway 98 North
Okeechobee, FL 34972-2303
Ph: (863) 763-8124 Fax: (863) 763-2164
E mail: bgrinslade@co.okeechobee.fl.us

Dade City Office:
Paul Comeau, Darrel Davis
13853 15th Street, Dade City, FL 33525
Ph: (352) 521-5172 Fax: (352) 521-5176
E mail: pcomeau@pascocountyfl.net
PINELLAS

ORANGE
Edward Alexander, Senior Veterans Counselor
2100 E. Michigan St., Orlando, FL 32806
Ph: (407) 836-8990 Fax: (407) 836-8999
E mail: Edward.Alexander@ocfl.net

N Royce Carter
Mike Hill, Senior VSO
Eric Cobelens, VSO

Lannie Thomas
2189 Cleveland St., #201, Clearwater, FL 33765
Ph: (727) 464-8460 Fax: (727) 464-8463
E mail: dstout@co.pinellas.fl.us

Ibrahim Rosado, Veterans Counselor
VAHCC, 5201 Raymond St., Bldg. 3126
Orlando, FL 32803
Ph: (407) 599-1506 Fax: (407) 599-1508

29

Michael Dowling, VSO
501 1st Avenue N., #517, St. Petersburg, FL 33701
Ph: (727) 582-7828 Fax: (727) 582-7813

SARASOTA
Jerry Derrick, CVSO
Greg Worth VSO, Randy Mayer VSO
Terry Acton VSO, Tom Carhart VSO, Gary Valinski VSO
2200 Ringling Blvd., #125, Sarasota, FL 34237
Ph: (941) 861-2899 Fax: (941) 861-2571
E mail: jderrick@scgov.net
4000 S. Tamiami Trail, #139, Venice, FL 34293
Ph: (941) 861-3047 Fax: (941) 861-3024
E mail: ggworth@scgov.net

Wed. only, by app’t: Tarpon Springs SPC Campus
38500 US 19 North, Tarpon Springs, FL 34689
Ph: (727) 324-2848
POLK
John Hopkins, CVSO
Ernie Roberts, Service Officer
Edwin Wright, Service Officer
Roger Puffer, Service Officer
1290 Golfview Ave., Ste. 116, Bartow, FL
Mail to: Polk County Veteran Services (HS-08)
PO Box 9005, Bartow, FL 33830
Ph: (863) 534-5220 Fax: (863) 534-7378
E mail: JohnHopkins@polk-county.net

SEMINOLE
George Tingle, VSO
Anthony Montville, Assistant VSO
534 West Lake Mary Blvd, Sanford, FL 32773-7400
Ph: (407) 665-2370 Fax: (407) 665-2379
E mail: gtingle@seminolecountyfl.gov

PUTNAM
Thomas Moltimore, CVSO
515 Reid St., #1D (Mail to: PO Box 771)
Palatka, FL 32178
Ph: (386) 329-0327/8/9 Fax: (386) 329-0329
E mail: thomas.moltimore@putnam-fl.com

SUMTER
Dan Baker, Manager
Carolyn Allfrey, VSO
Paul Cheek, Christine Hodges VSO’s
416 Lawrence St., Bushnell, FL 33513
Ph: (352) 793-0235 Fax: (352) 793-6880
E mail: Dan.Baker@sumtercountyfl.gov

ST. JOHNS
Joseph D. McDermott, CVSO
Richard Rees, Assistant VSO
Heather Andrews, Assistant VSO
1955 US 1 South, #550, St. Augustine, FL 32086
Ph: (904) 209-6160 Fax: (904) 209-6161
E mail: jmcdermott@sjcfl.us

Richard Dobson, Debbie Smith-- Service Officers
8033 E CR 466, Ste. B, Box 9, Lady Lake, FL 32162
Ph: (352) 753-2686 Fax: (352) 568-6676
E mail: Richard.Dobon@sumtercountyfl.gov
SUWANNEE
William A. Fletcher
Mon-Thurs: 8:00am-5:00pm
224 Pine Ave., Live Oak, FL 32060
Ph: (386) 364-3403 Fax: (386) 364-4038
E mail: wfletch@alltel.net
TAYLOR
Vacant
Taylor County Sports Complex
1685 N. Highway US 19, Perry, FL 32348
Office Hours: Mon. and Wed., 8:00am-5:00pm, or by
Apptmt; Ph: (850) 838-3513 Fax: (850) 838-6563
E mail: jcvc@gtcom.net

ST. LUCIE
Paul J. Hiott, Director
Donna Carlsen, Helen Simpson, VSO II
Larry Coleman, Orlando Batista, VSO
Mailing Address:
2300 Virginia Ave., Ft. Pierce, FL 34982-5653
Ph: (772) 337-5670 Fax: (772) 337-5678
E mail: veterans@co.st-lucie.fl.us
Walk-in Location:
1664 S.E. Walton Road, Port St. Lucie, FL 34952
Walk-in Location:
437 N. 7th Street, Ft. Pierce, FL 34950
SANTA ROSA
Karen L. Haworth, CVSO
6491 Caroline St., Ste. #1, Milton, FL 32570
Ph: (850) 626-8724 Fax: (850) 983-8970
E mail: karenh@santarosa.fl.gov
Santa Rosa County Service Center
5841 Gulf Breeze Pkwy, Gulf Breeze, FL 32563
Ph: (850) 932-9508

UNION

Seneca “Buddy” Austin, CVSO
15 NE First Street, Lake Butler, FL 32054
Wednesdays from 8:30am-Noon
Ph: (386) 496-4248 Fax: (386) 496-4810
E mail: unioncountyvso@windstream.net

30

SOUTHERN GEORGIA:
Central Office for Veteran Services
Floyd Veterans Memorial Building
Suite E—970
Atlanta, GA 30334-4800
Ph: (404) 656-2300 or (404) 656-5933 or (404) 9295345 Fax: (404) 656-7006
E mail: gavetsvc@vs.state.ga.us

VOLUSIA
Michael White, Director
E mail: Mwhite@co.volusia.fl.us
Patricia R. Antol, Senior Veteran Counselor
Joyce Lawler, Veteran Counselor
123 West Indiana Ave., #100, Deland, FL 32720
Ph: (386) 740-5102 Fax: (386) 740-5101
E mail: pantol@co.volusia.fl.us

At http://sdvs.georgia.gov you can click on individual
counties in South Georgia to find out exact contact
information..

Dale W. Swartzfager, Veteran Counselor
Yvette E. Graham, Veteran Counselor
250 N. Beach St., Daytona Beach, FL 32114
Ph: (386) 254-4646 Fax: (386) 239-7764
E mail: MWhite@co.volusia.fl.us
Charlton Hines, Senior Veteran Counselor
M-W-F only
2765 Rebecca Lane, Suite C, Orange City, FL 32763
Ph: (386) 775-5205 Fax: (386) 775-5208
E mail: chines@co.volusia.fl.us
Charlton Hines, Senior Veteran Counselor
Tues & Thurs only, New Smyrna Office
Ph: (386) 423-3324 Fax: (386) 775-5208
(Send all mail to Orange City office)

PUERTO RICO:
Executive Director: Luis Ramos Gonzalez
E mail: luisramos@opv.gobierno.pr
Or: opvpr@yahoo.com

Don Morgan
196 Ochlockonee St (PO Box 849)

Mercantil Plaza Bldg.
Fourth Floor, Suite 4021
Hato Rey, PR 00918-1625
Ph: (787) 758-5760 Fax: (787) 758-5788
Mailing Address:
Puerto Rico Public Advocate for Veterans Affairs
P.O. Box 11737, Fernandez Juncos Station
San Juan, PR 00910-1737
US VIRGIN ISLANDS:
Director: Justin Harrigan, Sr.
E mail: justinova46@yahoo.com

, Crawfordville, FL 32326
Ph: (850) 926-5289 Fax: (850) 926-6255
Hours: Mon-Fri 8:00am-5:00pm
E mail: anelson@mywakulla.com

1013 Estate Richmond
Christiansted, St. Croix VI 00820-4349
Ph: (340) 773-6663 Fax: (340) 692-9563

WAKULLA

WALTON
Phil McMillian
312 College Ave., Unit A
Defuniak Springs, FL 32435
Ph: (850) 892-8140 / 8141 Fax: (850) 892-8148
E mail: mcmphil@co.walton.fl.us
WASHINGTON
Amy Simmons, CVSO
1331 South Blvd., Chipley, FL 32428
Ph: (850) 638-6140 Fax: (850) 638-6145
E mail: vetsrus@washingtonfl.com

31

SECTION IV: FINDING A JOB
Incarcerated Veterans Transition Program (IV-TP): Managed by the U.S. Department of Labor and the
Veterans’ Employment and Training Service (VETS), this program helps ex-offender veterans who are at risk
of homelessness to re-enter the workforce. It uses a case management approach to link incarcerated vets with
appropriate employment and life skills support as they transition from correctional facilities back into the
community. It offers assistance with job searches, trainings, placements, and follow up after placement. This
program is eligible to veterans with honorable discharges who are within 18 months of release. More
information on line at www.dol.gov/vets.
Homeless Veterans' Reintegration Projects (HVRP) is also managed by the U.S. Department of Labor and
the Veterans’ Employment and Training Service (VETS). It is a federally funded program that provides
employment and training services to homeless veterans to help them get back into the workforce. HVRP assists
veterans with job placement, training, job development, career counseling, resume preparation, trade skills
certification and licensing. Supportive services such as clothing, provision of or referral to housing, referral to
medical and substance abuse treatment, and transportation assistance may also be provided . To find out if you
are eligible, contact the VETS office near you, listed in the phone book under United States Government, U.S.
Dept. of Labor or go online to www.dol.gov/vets/aboutvets/contacts/main.htm.
Workforce Florida/ WorkSource Centers/ One-Stop Career Centers: Veterans can find the services they
need at a convenient One-Stop Career Center. Work with a veterans employment specialist to find jobs, acquire
skills and education, plan your career, attend workshops and take advantage of other resources. Search the
directory for the One-Stop Career Center near you, or go online www.servicelocator.org , or just pick up the
phone and dial 1-877-US2-JOBS for direct assistance!
The Work Opportunity Tax Credit (WOTC) can save an employer as much as $2,400 in taxes when they
hire a worker who historically has had a hard time landing a job. All an employer has to do is hire a qualified
worker, fill out the Pre-Screening Notice (8850) and Individual Characteristics Form (9061) and drop them in
the mail within 21 calendar days from the start date of employment. An ex-felon who has a hiring date which is
not more than one year after the last date on which they were convicted or released from prison, and is a
member of an economically disadvantaged family is qualified for WOTC. Employers can call the WOTC Unit
at 1-800-669-9271, or contact their local WorkSource/ One-Stop Career Center.
Workforce Innovation - Federal Bonding Program A Fidelity bond is NO COST insurance coverage meant
to allow employers to hire job applicants considered “at risk” due to their past life experiences. The employer
gets the worker’s skills, abilities and knowledge without risking liability for potential employee dishonesty.
There are no forms for the employer to sign, and no processing to delay matters – the insurance can be put into
effect instantly. The bond insurance can apply to any job and covers any employee dishonesty that occurs on or
away from the employer’s work facility An employee can be bonded for at least $5000, starting the first day of
employment, and covering a six-month period.
AGENCY FOR WORKFORCE INNOVATION –AWI
107 East Madison Street Caldwell Building
Tallahassee, Florida 32399-4120
Phone: (850) 245-7105 Fax: (850) 921-3223 (or at the local One Stop/County Empl. Office).
32

ADDITIONAL ONLINE RESOURCES AND/OR CONTACT NUMBERS
HEALTH
1) National Health Care for the Homeless Council Information on medical, legal, housing, family issues, etc.
@ www.nhchc.org
2) MyHealtheVet
Provides a way for you to manage your health and seek
services online @ www.myhealth.va.gov
3) National Suicide Support
1-888-SUICIDE (784-2433)
4) VA Suicide Hotline:
1-800-273-TALK (8255) or call your local VA Medical
Center or Vet Center; Locate Vet Centers @
www1.va.gov/directory/guide/vetcenter_flsh.asp?
5) National Crisis Hotline
1-800-784-2433
6) National Alliance for the Mentally Ill
Grass roots organization offering information and support
@ 1-800-950-6264 or www.nami.org
7) National Mental Health Association
Answers to frequently asked questions, assistance finding
help, paying for care, medication assistance, support groups
and more @ 1-800-969-6642 or online @ www.nmha.org/
8) Focus on Recovery Helpline (drug/alcohol)
1-800-374-2800 or 1-800-234-1253
9) Substance Abuse and Mental Health Services Administration (SAMHSA) 1-800-662-4357
Find treatment facilities @ dasis3.samhsa.gov/
10) National AIDS Hotline
1-800-CDC-INFO (800-232-4636)
11) National HIV/AIDS Program
www.hiv.va.gov/
12) Florida AIDS Hotline
1-800-FLA-AIDS (352-2437)
Get basic information on HIV/AIDS, Hepatitis, testing by
county, patient care services, etc. @
www.doh.state.fl.us/disease_ctrl/aids/index.html
13) Georgia AIDS Hotline
1-800-551-2728 or go online to infoline@aidatlanta.org

HOUSING/HOMELESS PROGRAMS
1) National Coalition for Homeless Veterans
2) Veterans Assistance Foundation
3)

4)
5)
6)

1-800-VET-HELP (838-4357) or www.nchv.org
Resources, programs, services for vets who meet eligibility
requirements; online @ www.veteransassistance.org
VA Homeless Programs
Online @ www1.va.gov/homeless ; Listing of Health Care
for Homeless Veterans (HCHV) Coordinators by State
online @ www1.va.gov/homeless/page.cfm?pg=21
Florida Coalition for the Homeless
Directory of service providers assisting homeless people in
Florida @ www.fchonline.org
Homeless Shelters Directory
www.homelessshelterdirectory.org
Homeless shelters/food/jobs/HUD/resources for the homeless listed by State @
www.ibiblio.org/rcip/shelters.html

33

LEGAL
Florida Institutional Legal Services

Civil Legal Assistance Project, Gainesville FL
Public interest law firm providing legal services to
institutionalized and low income persons; no website;
located at 1010-B N.W. 8th Ave, Gainesville, Fl 32601;
phone number 352-375-2494

Florida Legal Services

State support center for legal service providers; offers
legislative and administrative advocacy on issues impacting
the poor; provides technical assistance to those advocating
in the field; www.floridalegal.org

Georgia Law Center for the Homeless

Provides outreach services at shelters, transitional housing
facilities, community kitchens, etc.; phone: 404-681-0681
or online @ www.galawcenter.org/

Atlanta Legal Aid Society

Listing of legal services and available programs; phone:
404-524-5811 or online @
www.atlantalegalaid.org/others.htm

FORMS NEEDED TO ENROLL IN VA HEALTH CARE
Below are brief descriptions of the three most important forms you will need to file when applying for VA
benefits. Copies of these forms have been included for your use at the back of this Guidebook. You will be
asked to complete more forms in the future, but these three are necessary to get your enrollment in the VA
System started. Send them to the VA Hospital or Clinic you plan on using for health care. Keep a copy for
your records.
Standard Form-180 – Request Pertaining to Military Records — This 1-page form is used to get copies of
your Record of Discharge (DD-214), military personnel and medical records. You will need a copy of your DD214 when applying for any benefits. Requests may also be completed online at http://vetrecs.archives.gov.
VA Form 10-10EZ –Application for Health Benefits — This 3-page form is used by the VA to determine if
you can receive medical benefits. Complete the form and bring it with you to the VA medical facility where you
will be seeking evaluation and treatment.
Supplement to VA Form 10-10EZ — This 2-page form asks for some of the same information requested on
Form 10-10EZ, in a more simple form, as well as additional information. Submit this form along with Form
10-10EZ.

34

35

36

37

38

SUPPLEMENT TO VA FORM 10-10EZ
VETERAN’S NAME (Last, First, Middle) :__________________________________________________________
FATHER’S NAME: _________________________________________________
MOTHER’S NAME: __________________________ MOTHER’S MAIDEN NAME: _____________________
PLACE OF BIRTH (City & State): ___________________
DIVORCED? YES / NO DATE:______________ WIDOWED? YES / NO DATE: _______________
EMPLOYER:_______________________ ADDRESS:______________________________________________
CITY:________________ STATE:_____ PHONE:(___)____________OCCUPATION: ____________________
SPOUSE’S EMPLOYER:_______________________ ADDRESS:______________________________________
CITY:________________ STATE:_____ PHONE:(___)____________OCCUPATION: ____________________

Have you ever received care at another VA? Yes ____ No ____
Where: Location (City & State)____________________ When: Most recent date of care:___________
Combat Service: Yes or No (Circle) Combat Dates to:______________ From______________
Location of Combat Circle one or more locations: WWII Korean Vietnam
Persian Gulf OEF/OIF The Office of
the Surgeon General requested that VA collect race and ethnicity information from all of our patients. Please
check the boxes that apply to you.
Ethnicities: (Check one)

Privacy Act Information: The VA is asking you to provide the
information on this form under Title 38, United States Code
sections 1710, 1712, and 1722. The information is collected at
the request of the Surgeon General and will help us track diseases
that are more common in certain races and ethnicities. VA may
disclose the information that you put on the form as permitted by
law. VA may make a “routine use” disclosure for: civil or
criminal law enforcement, congressional communications,
epidemiological or research studies, the collection of money
owed to the United States, litigation in which the United States is
a party or has an interest, the administration of VA programs and
delivery of VA benefits, verification of identity and status, and
personnel administration. Failure to furnish the information will
not have any affect on any other benefits to which you may be
entitled. If you give VA your Social Security Number, VA will
use it to administer your VA benefits, to identify veterans and
persons claiming or receiving VA benefits and their records, and
other purposes authorized or required by law.

______Spanish, Hispanic, or Latino
______No, not Spanish, Hispanic, or Latino
Race: (Check one or more)
______American Indian or Alaska Native
______Black or African American
______Native Hawaiian or Other Pacific Islander
______White
______Asian

Signature of Veteran ____________________________________

39

Date____________