Veteran’s Aid and Attendance Form

Your Name (required)

Phone Number (required)

Your Email (required)

For whom are you requesting this information

Subject

Your Message

Is applicant currently living in a Nursing Home or Assistant Living Center?

Applicant Name

Applicant Age

Marital Status

Spouse Name

Spouse Age

Current Address

City

State

Current Resident Type

Do you rent or own?

Monthly Payment

Property Value

Do you plan to live in assisted living soon?

If so, what do you plan on spending per month?

Is the veteran age 65 or older?

Permanently Disabled?

Is the un-remarried surviving spouse the last spouse of the Veteran at the time of his death?

Did the Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?

Did the deceased Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?

Did the Veteran receive an honorable or general discharge?

Did the deceased Veteran receive an honorable or general discharge?

Medical Diagnosis

Select the activities of daily living this person requires assistance with: (Hold Control when selection multiple options)

Income of Veteran

Social Security

Pensions

Interest Income

Total Monthly Income

Expenses

Medicare Part-B

Private Medical Insurance/Medicare Supplement

Senior HMO

Monthly Home Care Costs

Monthly Cost of Facility

Cost of Long Term Care Insurance

Total Monthly Medical Expenses

Savings

Checking, Savings, CDs

Stocks, Bonds, Mutual Funds

IRA

Total Asset/Savings


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