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  2. Veterans Certification & Questionnaire for Benefits

<h1><span style="color: #132644;"> &nbsp &nbsp Veterans Certification Questionnaire</h1>

    • 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.
  • 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 Information

    Information about the Veteran.

    If requesting information for the Spouse of Veteran or Widow,
    you will answer those questions later.

  • US Army, US Air Force, USCG, US Navy, USMC, Merchant Marines
  • Please enter a number from 1 to 120.
  • All remaining question will refer to the Recipient as the Claimant

  • Claimants Monthly Income

    Please ensure all income disclosure is calculated at the gross monthly rate in this section.

  • Leave blank if N/A - Amount Format e.g. 1,250.00

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Please furnish amount and type of claim awarded
  • This section will discuss Medical Costs paid by the Claimant!

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Household Cash Assets

  • Leave blank if N/A - Amount Format e.g. 1,250.00
  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

  • Amount

    Whether occupied or not by Veteran and/or Spouse
  • Amount

  • Amount

  • Form Completion & Additional Contact Information

  • Immediate family, e.g. Daughter, Brother or person in charge of affairs/power of Attorney etc e.g. Family Lawyer.
  • With 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.

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