Pre-Qualification Form

See if you qualify for the Veterans Aid & Attendance Pension.

This eligibility request helps us more accurately determine if you (or your loved one) meets the criteria for certain veterans benefits. Please complete each field as accurately as possible. This information is required by the Department of Veterans Affairs to assess eligibility. All information provided will remain confidential and used strictly for evaluation purposes. Disclosure of personally identifiable information shall not be made to any third party without your express permission. Thank you

Information Requested By
First & Last Name*:
Address*:
Home Number*:
Email*:
For whom are you requesting this information:
Does the senior plan on living in assisted living or start home care services soon?	Assited Living Home Care
If so, what do you plan on spending per month?:
Tell Us About The Veteran
Name of Veteran:
Age:
Marital Status:
Spouse's Name:
Age:
Current Address:
Current Resident Type:
Do you own or rent:
Does the veteran own real estate other than his/her primary residence? Yes No
Monthly Payment:
Property Value:
Service Related Questions
Is the Veteran age 65 or older, or permanently disabled?:
Did the 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?:
Is the Veteran spending at least 75% of his/her monthly income on medical expenses? (including RX, health insurance, home health care, assisted living, and/or nursing home expenses):
Is the un-remarried surviving spouse the last spouse of the Veteran at the time of his death?:
Did the deceased Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?:
Did the deceased Veteran receive an honorable or general discharge?:
Is the surviving spouse spending 75% or more of his/her monthly income on medical expenses? (including RX, health insurance, home health care, assisted living and/or nursing home care)?:
Health Questionnaire
Select the activities of daily living this person requires assistance with:	Medicating Bathing Dressing Toileting Transferring Eating
Medical Diagnosis:	Alzheimer's Dementia
Monthly Income/Expense Questionnaire
INCOME	Veteran	Spouse
Social Security:
Pensions:
Interest Income:
VA Retirment or Disability:
Rental Income:
Other:
Total Monthly Income:

EXPENSES	Veteran	Spouse
Medicare Part-B:
RX Co-Pays:
Doctor Visit Co-Pays:
Private or Facility Health Care Cost:
VA Health Benefits TRICARE:
Long Term Care Insurance Premiums:
Personal Care / Home Health Care:
Private Medical Insurance:
Total Monthly Medical Expenses:

SAVINGS	Veteran	Spouse
Checking, savings, CDs:
Stocks, bonds, mutual funds:
IRA's:
Other:
Total Asset/Savings:

	I respect your privacy. Your information will not be given/sold to any other entity.