EmailMe Form - VA Aid & Attendance Pre-Qualification Form

Date Time *

MM / DD / YYYY

Name *

First Last

Phone *

### - ### - ####

Email *

Client Type *

Veteran

Surviving Spouse

Couple

1. Was the Veteral honorably discharged? *

Yes

No

2. Did the Veteran serve at least 90 consecutive days of active duty, with at least one (1) day during any of the following wartime periods? *

Yes

No

If yes, check applicable wartime period. *

WWII 12/07/1941 - 12/31/1946

Korea 6/27/1950 - 01/31/1955

Vietnam 8/05/1964 - 05/07/1975

Vietnam 2/28/1961 - 08/05/1964 (Must have been in the Republic of Vietnam)

Gulf War 8/02/1990 – TBD (must be active duty 2 years)

3. If surviving spouse, were you married to the veteran at the time of death? *

Yes

No

4. If surviving spouse, did you remain unmarried after the Veteran’s death? *

Yes

No

5. Is there a need for assistance with Activities of Daily Living? (Bathing, Dressing, Transportation, Incontinence, Housekeeping, Laundry, Cooking, Meal Prep, Shopping) *

Yes

No

6. Are assets less than $80K? (Cash, checking, 6. savings, CD’s – excludes car & home) *

Yes

No

Check if known: *

Less than $20k

$20k - $40k

$50k-$80k

Unknown

7. Is the veteran or surviving spouse already receiving VA money? *

Yes

No

Note:

We are partners with Veterans Care Coordination, LLC, (VCC), who are not associated with any government agency. VCC cannot offer legal advice or guarantee eligibility for monetary compensation or the Aid & Attendance Pension.