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Request Eligibility Information
Please Fill Out and Submit
As a veteran, are you at least age 65, served at least one day during the following periods and had 90 days of continuous military service with an honorable discharge?
World War II:
December 7, 1941 through December 31, 1946
Korean War:
June 27, 1950 through January 31, 1955
Vietnam War:
Aug 5, 1964 (Feb 28, 1961, for veterans who served in country), through May 7, 1975
Gulf War:
Aug. 2, 1990, through a date to be set by law of Presidential Proclamation.
Yes
No
Select which war you were in:
World War II
Korean War
Vietnam
Gulf War
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Do you need assistance with any of the following Activities for Daily Living (ADLS)?(required)
.
Medicating
Bathing
Dressing
Toileting
Transferring
Eating
N/A
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Assests
Estimated total assets (exclude home and car)
(Checking, savings, stocks, investments, IRAs, other property, etc.)
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Income
Estimated total annual income from all sources (If married include spousal income):
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Un-reimbursed Expenses
List all unreimbursed, recurring health care expenses:
This includes:
Assisted Living costs (per month):
Nursing Home costs (per month):
Home health care service (per month) :
Health Insurance premium (per month) :
Medicare premium (per month) :
Regular (unreimbursed) prescriptions per month & verifiable through a pharmacy print-out) :
TOTAL Deductible Expenses :
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Name of Veteran
(required)
Age of Veteran
(required)
Name if other than Veteran
Relationship to Veteran:
Surviving Spouse
Son
Daughter
Other
Phone
(required)
Email:
(valid email required)
By clicking Submit you agree for us to contact you via email or phone regarding information submitted in this form.
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