Skip to form

City of Worcester

455 Main Street, Worcester, MA, 01608, US

Veterans' Services Letterhead Image


M.G.L. Chapter 115 Veterans' Safety Net Program Pre-Eligibility Screening

By filling out the application below you certify that you are the Veteran, family of a Veteran or someone legally appointed to act on behalf of the Veteran or family of a Veteran. You acknowledge that you are in need of financial assistance. The program you are applying for is NOT under the federal VA system; this is a benefit available only to residents of the Commonwealth of Massachusetts. By filling out this form, you acknowledge that you are a resident of the City of Worcester. If you do not live in Worcester, please contact your city or town hall to locate your Veterans' Service Officer (VSO). Once the form is completed and submitted, it will be sent to the Worcester Veterans' Services Office for review. You will be contacted by the Office to acknowledge receipt of your application and to let you know what paperwork will be required when you come in to complete your application.

*Information submitted in the following form is secure and will not be shared with anyone outside of the Veterans' Services Office.

Do you reside (live) in Worcester?

Non-Worcester residents will need to locate a VSO (Veteran Service Officer) in the area where you live. Use the link below to find your VSO:

Full Name

Character of Service

Combat Veteran?

Do you have a copy of your DD214 or verification of military service?

Please upload a copy of the DD214 or supporting documents.

Click Here to Upload

You can access a copy of your DD214 two ways; note Ch.115 services cannot start until your DD214 is verified and you meet Ch.115 program requirements. Thus, getting a copy of your DD214 to the Veterans Department may delay services.

  1. Visit the Military Records Website so you can order a copy yourself.
  2. Download the Form SF 180, print a copy, complete the form, sign and date the form. You can bring the completed form to our office located at 455 Main Street, Room 101, Worcester, MA 01608.


Are you Married?

Do You Live Together?

Name of Spouse

Is Your Spouse Also a Veteran?

Do you have biological children, legally adopted children or other dependents living in your household?

Do You Owe Child Support?

Do You Own an Automobile?

Do You Pay Rent or Own?

Is Heat Included?

Is There a Mortgage on the Property?

Type of Property

Do You Receive Rental Income?

Do You Have Fuel Assistance?

Tell Us About Your Income

I understand VA pay, VA compensation or retirement pay is considered income for this program and must be listed as income below.

Check All Boxes that Apply and the Amount You Receive in the Extra Fields that Will Display.

Is Medical Insurance Being Deducted from Your Retirement or Pension?

If on Social Security, Are You Paying for Medicare?

Do You Have Any Claims Pending (VA, SSA, Other)?

Tell Us About Your Spouse's Income. Check All Boxes that Apply and the Amount You Receive in the Extra Fields that Will Display.

Is Medical Insurance Being Deducted from Your Spouse's Retirement or Pension?

If Spouse on Social Security, Are They Paying for Medicare?

Does Your Spouse Have Any Claims Pending (VA, SSA, Other)?

Do You Have a Life Insurance Policy?

Do You Have Health Insurance?

Do You Have a Bank Account, Including Prepaid Debit Card Accounts (Direct Express, NetSpend, Green Dot, Etc.)?

Do You Have a Digital-Only Cash Exchange Account (PayPal, Venmo, Zelle, Cash App, Etc.)?

Do You Have Any Stocks, Bonds, IRAs, 401Ks, CDs or Money Markets?

Do You Have Any Lawsuits Pending?

Are You Able and Looking for Employment?

Have You Applied for SSI, SSDI or VA Benefits?

Applicant's Voluntary Self-Identification

This information is collected to make sure everyone is treated fairly. Your answers are voluntary and will not affect eligibility or amount.

Primary Language

Special Situation (Check All That Apply)

Are You a US Citizen?

Sign Here

Choose how to sign