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Single Veteran Form by
Start by filling out the information.
1) Did the Veteran serve at least 1 day of active duty during any of the following wartime periods?
World War II: December 7, 1941 through December 31, 1946
Korean Conflict: June 27, 1950 through January 31, 1955
Vietnam Era: August 5, 1964 through May 7, 1975. Veterans who served in the Republic of Vietnam between November 1, 1955 and August 4, 1964 are also eligible.
American Merchant Marines in Oceangoing Service during the Period of Armed Conflict: December 7, 1941 through August 15,1945
None of the above
2) Did the Veteran serve a minimum of 90 days of active duty and receive an honorable, general or medical discharge?
3) Is the Veteran receiving Disability Compensation from the VA? Do not include career military pensions.
Health And Medical
Does the Veteran need assistance with two Activities of Daily Living OR do they require a protected environment due to physical or cognitive disabilities. If not now, might they in the near future?
What Care Are You Receiving
5) Does the Veteran pay a home care agency for assistance with activities of daily living or to ensure a protected environment? If not now, might they in the near future?
6) Which of the following options best describes the Veteran's living situation?
They live in their own home or someone else's
They currently live in an independent living facility or expect to move into one in the near future
They currently live in an assisted living facility or expect to move into one in the near future
Income And Expenses
7) What is an estimate of the Veteran’s monthly assisted living, independent living, home care and health insurance premiums?
8) Does the Veteran have Long Term Care Insurance?
9) What is the Veteran's estimated total monthly income?
Income And Expenses
11) What is the estimated value of the Veteran's liquid assets? (bank accounts, annuities, IRAs, CDs, stocks, and brokerage accounts)
12) Did the Veteran gift or transfer any assets, other than the primary residence, to a family member, friend or irrevocable trust in the last 36 months?
13) Did the Veteran purchase a monthly income annuity/immediate annuity in the last 36 months?
14) Has the Veteran prepaid their funeral and burial expenses?
15) Does the Veteran own a home?
16) Does the Veteran own any other real estate?
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