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Veteran's Aid & Attendance Pension - Information Request Form
*
Required Field
Caller Name
*
Relationship to Veteran
Caller Home Phone
*
Caller Work Phone
Caller Email Address
*
Confirm Email Address
*
Claim Type
Veteran W/O dependent
Veteran W/dependent
Surviving Spouse of Veteran
Name of Veteran
Age
Spouse Name
(If applicable)
Age
Veteran lives currently in
City
State
Zip
Veteran Tel.
Home#
Cell #
Other #
Claimant Lives In
Private Residence/Apt.
Assisted Living Facility
Other
Explain if other
Please answer the following questions
YES
NO
Was the veteran on active duty for 90+ days of which at least one day was during a war?
Approximate dates of service?
Was the veteran honorably discharged?
If a surviving spouse, was he or she married to the veteran at the time of his or her death?
Is the claimant's approximate income AFTER healthcare expenses less than $2000/Month?
Does the claimant have less than $80,000 in liquid assets or investments? (excluding home/car)
Does the veteran or surviving spouse need assistance with activities of daily living?
Comments or questions:
*
Required Field
Please type the text in red below:
For more information about how to join us
in “Serving America’s Heroes,”
please call today. 866.507.0003
Veterans ElderCare Consulting LLC- 11924 West Forest Hill Blvd, Suite 22-169, Wellington - Florida 33414 - Phone 866.507.0003
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