The following items are blank or not valid and must be updated:
First Name
*
Last Name
*
Phone
*
e.g. 555-555-5555
Email
*
Were you injured, held captive, or forced to relocate by ISIS?
*
Yes
No
Were any of your family members injured, held captive, forced to relocate, or killed by ISIS?
*
Yes
No
Are you now a U.S. citizen (there is no requirement that you were a U.S. citizen at the time of the attack)?
*
Yes
No
What was the date of the attack? (if you are unsure of the exact date, please use your best estimate)
*
What was the nature of the attack where you were injured?
*
EFP
IED
RPG
Mine
Mortar
Rocket
Grenades
Small Arms
Other
Describe the injury you sustained:
*
When would be a good time to call you?
--Select--
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm
Anytime
Central Time
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