Veterans Certification Questionnaire I certify that: (This button must be clicked to "Green" to proceed).* Yes You or your spouse is Veteran of the US Armed Forces The Veteran must have served 90 continuous days in Active Duty. The Veteran must have served just one (1) day during a War or Conflict but not necessarily in a Combat Zone, during:. World War II, Korean War, Vietnam War or Gulf Wars. The Veteran must have received an Honorable or Administrative Discharge (not Dishonorable). Note: Veterans surviving spouses (widow/widower) can fully qualify if all criteria above are met. Who directed you to this page?* Susan Battaglia, National Director Tyrone Borger Harve Senter Jim Florio Arthur Toole Bernie Esberner Other Other If you were referred by another Person or Facility, or found us via web search, please type details in the "Other" box. e.g. Google Search, Evergreen Assisted Living etc. Thanks!Information concerning the Veteran's Assets and Income are requested in this form. If you do not have information about the Veteran and/or Spouses assets and income, please gather that so you may submit an accurate financial assessment required by the Dept. of Veteran affairs when the official forms are executed. Scroll down the page to review the information before proceeding. Other Questions may appear depending on the answers given.Veteran InformationInformation about the Veteran.If requesting information for the Spouse of Veteran or Widow, you will answer those questions later.Name of Veteran?* First Last Dates of Military Service? Veteran Living or Deceased* Living Deceased Branch of US Armed Forces US Army, US Air Force, USCG, US Navy, USMC, Merchant MarinesAge of Veteran?*Please enter a number from 1 to 120.Where does the Veteran currently reside?* At Home Independent Living Community Continuing Care Community Assisted Living Facility Alzheimer's/Memory Care Facility Skilled Nursing Facility Residential Care Facilitiy Name of Facility? Veterans Home Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Status of the Possible Recipient?* Single Veteran Veteran with Spouse Two Married Veterans Spouse requiring care with Healthy Veteran Phone number of Veteran?Does the Veteran receive any income from a Deceased Spouse? Yes No How much is the monthly amount and from what source(s)? Spouse's Name First Last Spouse's Age Name of Widow? First Last Age of Widow? Does the Widow receive any income from a Deceased Veteran? Yes No How much is the monthly amount and from what source(s)? All remaining question will refer to the Recipient as the ClaimantWhere does the Claimant reside?* At Home Independent Living Community Continuing Care Community Assisted Living Facility Alzheimer's/Memory Care Facility Skilled Nursing Facility Residential Care Facilitiy Please list Medical Conditions of ClaimantName of Facility? Address of Care Facility or Community Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does the Claimant receive "In Home Care"? Yes No The Home Health Care Agency and/or Caregivers name. Claimants Monthly IncomePlease ensure all income disclosure is calculated at the gross monthly rate in this section.Social Security Income - ClaimantLeave blank if N/A - Amount Format e.g. 1,250.00Social Security Income - SpouseAmount Social Security Disability Income - ClaimantAmount Social Security Disability Income - SpouseAmount Pension & Retirement Income - ClaimantAmount Pension & Retirement Income - SpouseAmount Existing Dept. of Veteran Affairs Monthly Claim IncomePlease furnish amount and type of claim awardedThis section will discuss Medical Costs paid by the Claimant!Long Term Care Insurance Policy - Active Disbursement Yes No Long Term Care policy monthly disbursementAmount Care Facility or Community total monthly cost.Amount Monthly In-Home Care paymentAmount Medicare Part B Insurance premium*Amount Medicare Part D Insurance Premium*Amount Medicare Supplement monthly premium.*Amount Other Health Insurance or Supplement monthly premium.Amount Monthly cost for Long Term Care Insurance Premiums, if any?Amount Household Cash AssetsChecking Account - Current BalanceLeave blank if N/A - Amount Format e.g. 1,250.00Savings Account Balance?Amount Certificates of Deposit, Total BalanceAmount Stock/Bond Balance in Dollars?Amount Mutual Fund Balance?Amount Total Annuity(s) Balance?Amount Investment Retirement Account - IRAAmount Life Insurance Policy - Claimant Yes No Death Benefit Amount(s) - Life PolicyAmount Cash Value Life Insurance - ClaimantAmount Claimant owns his/her home Yes No Whether occupied or not by Veteran and/or SpouseHome Equity ValueAmount Other family owned property by Veteran/Spouse Yes No "Other" Property EquityAmount Form Completion & Additional Contact InformationName of person submitting this Certification* First Last Your Relationship with the Veteran Immediate family, e.g. Daughter, Brother or person in charge of affairs/power of Attorney etc e.g. Family Lawyer.Address of person completing this form* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone number of person completing this form!*Email address of the person completing this form.* Enter Email Confirm Email Other pertinent Veteran or Spouse/Family Information SectionWith the submission of this form, The Veteran Advocate assigned to your case will be better prepared to review your information for the Dept. of Veterans Affairs claims submissions and possible benefit and monthly payments for the US Veteran and/or Spouse and Survivor care services. Please submit the form when you have satisfactorily and to the best of your knowledge completed the minimum required information requested. Thank you for your time today.
