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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)
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:

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