APPLICANT INFORMATION
Name at time of entry into service:
Present name (if different):
Last
First Middle initial
Last First Middle initial
Address at time of entry into service:
Current address:
If address is outside the continental limits of the U.S.A., provide alternative contact information:
Street
City State
Street
City State
Email:
Name Street City State
Zip
code
Gender: Social security number: Date of birth:
Female Male
SSN
SERVICE INFORMATION
BONUS & DEPLOYMENT INFORMATION
(Revised September2011)
Date of discharge/separation:
Character of service:
Signature
:
I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and accurate.
PRINT THIS FORM AND SIGN YOUR NAME
Today's Date:
Steven Grossman
Treasurer and Receiver General
The Commonwealth of Massachusetts
Department of the State Treasurer
One Ashburton Place
Boston, Massachusetts 02108-1608
APPLICATION FOR WELCOME HOME BONUS: DISCHARGED SERVICEMEN & SERVICEWOMEN
[We recommend that you complete this form online and then print the entire packet.] Please use all CAPS
[Welcome Home Bonus- PAGE 1]
Apt/Suite
Apt/Suite
Apt/
Suite
Zip code
Zip code
Phone number:
Month Day Year
Which bonus or bonuses are you applying for? (Check off all that apply)
1st time: IRAQ or
AFGHANISTAN- $1000
Subsequent: IRAQ or
AFGHANISTAN- $500
1st time: 6+ continuous months
STATESIDE- $500 (One-time)
Subsequent: 6+ continuous
months FOREIGN SERVICE- $250
1st time: 6+ continuous months
FOREIGN SERVICE- $500
Date active service began:
Initial date of entry: Branch of service: Grade:
If you have already received a bonus, please list the dates of service for which you were paid (YYYY-MM-DD):
Please list the dates and locations of each overseas deployment for which you have not received a bonus. If stateside for 6+ continuous months, list dates of
service in 1st row. (Active service outside the continental limits of the U.S., AK, or HI. Section 16 Chapter 132 of the Acts of 2009 limits payment of subsequent bonus
to service overseas.)
From: To: Location:
Name of USS or overseas
country (if not IZ/AFG):
From: To: Location:
From: To: Location:
From: To: Location:
Name of USS or overseas
country (if not IZ/AFG):
Name of USS or overseas
country (if not IZ/AFG):
Name of USS or overseas
country (if not IZ/AFG):
(for most recent deployment)
Print Form
12/27/11
Office of Massachusetts State Treasurer Steven Grossman, Veterans' Bonus Division
CERTIFICATE OF RESIDENCY
(This should be completed by a Massachusetts city/town official)
ATTENTION: City/Town Official: The date of residency must be no more than one year
prior to the enlistment date or the most recent deployment date.
City or Town Name
(a) I, hereby certify that, according to the official records of this office,
resided at:
in the Commonwealth of Massachusetts of January first of the year: prior to
the veterans entry into the armed forces of the United States in the course of the Welcome Home Bonus.
(b) If applicant was a MINOR at the time of enlistment, kindly certify in section (a) of Certificate of
Residency, the name of veteran's father, mother, or legal guardian.
(c) I am unable to complete the above Certificate.
SEAL
[Welcome Home Bonus- PAGE 2]
(Revised September 2011)
Veteran's Name
Street Address
Signature of Official Printed Name & Title of Official Today's Date
Today's DatePrinted Name & Title of OfficialSignature of Official
,
,
Discharged Servicemen & Servicewomen
CHECKLIST
[Please include this page and utilize it to ensure all necessary documents are submitted. This application will not be
processed if the following documents are not submitted.]
Application:
I have completed, signed, and dated the application with my original signature on it.
Certificate of Residency:
The Certificate of Residency portion of the application must be signed and stamped by a city or town official. Please visit the city or
town hall in which you resided prior to your latest enlistment into the Armed Forces or your latest deployment. If you were a minor at
the time of enlistment, please have a parent’s or legal guardian’s residency certified. The date of residency on the certificate must be
no more than one year prior to your enlistment date or latest deployment date. In lieu of the certificate, we will accept a copy of your
High School Diploma/GED (if you enlisted right out of High School or up to a year after). We will also accept a copy of a W-2 tax form,
excise tax form or a copy of a rental or lease agreement from the required year.
I have completed the Certificate of Residency (with the original signatures on it) or included other accepted forms.
Proof of service and/or deployments: [WE CANNOT ACCEPT OIF/OEF AS PROOF OF IRAQ/AFGHANISTAN]
1) FIRST TIME:
a. 6 months Active Duty* ($500)- please include a copy of your DD214 Member 4**.
b. Iraq or Afghanistan ($1000)- please include a copy of your DD214 Member 4** specifically showing your location in Iraq
or Afghanistan. If your DD214 does not list dates and/or location, please provide additional proof, such as: orders showing
specific location in country and your name, a copy of your ERB (Enlisted Record Brief), ORB (Officer Record Brief), BIR (Basic
Individual Record), Flight Records, or Ship Itineraries.
2) SUBSEQUENT:
a. 6 months Foreign Service ($250)- please include a copy of your DD214 Member 4**.
b. Iraq or Afghanistan ($500)- please include a copy of your DD214 Member 4** specifically showing your location in Iraq or
Afghanistan. If your DD214 does not list dates and/or location, please provide additional proof, such as: orders showing
specific location in country and your name, a copy of your ERB (Enlisted Record Brief), ORB (Officer Record Brief), BIR (Basic
Individual Record), Flight Records, or Ship Itineraries.
*First time applicants can be either stateside or outside the continental limits of the United States not including Iraq or
Afghanistan. Stateside service does not apply to the Subsequent Bonus.
**This is the longer form which shows your Character of Service when separated.
I have included all necessary forms for proof of deployment(s).
PLEASE MAIL THE COMPLETED APPLICATION PACKET TO:
Office of the State Treasurer
One Ashburton Place, Room 1207
Boston, MA 02108
Attention: Welcome Home Bonus
Please contact our office at (617) 367-9333 ext. 859 with any questions.
[Welcome Home Bonus- PAGE 3]
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