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Veterans Aid & Attendance

CONFIDENTIAL INFORMATION

(Please include spouse information even if spouse is deceased)

Family Information – Please list all Children, Living and Deceased

V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse
V = Veteran S = Spouse JT = Client & Spouse

SERVICE INFORMATION

Dates of Service

Has the veteran received any of the following? (check if that apply)
$
$
$
$
$
Is the veteran (check if that apply)
Has Veteran ever filed a Claim with VA?

DISABILITY INFORMATION

NET WORTH AND INCOME INFORMATION

(if account in Column 1 is a joint account, only list once)

Monthly Medical Out-of-Pocket Expenses

List regular sources of gross monthly income and amounts (do not deduct taxes, Medicare premiums, etc):

UNREIMBURSED MEDICAL EXPENSES

Monthly Medical Out-of-Pocket Expenses

Please list your monthly medical out-of-pocket expenses (if married, please include spouse’s medical expenses as well).

Estate Plan Information - Do you have the following

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