* = Required Information
ROSPECTIVE CLIENT INFORMATION
Applicant is a VETERAN
Applicant is the SURVIVING SPOUSE of a Veteran
WWII KOREAN VIETNAM OTHER

If the veteran did not serve during wartime, the applicant will not qualify for the “Aid and Attendance” pension.

Yes No

If the answer to the above question is "Yes" the applicant will not qualify for the “Aid and Attendance” pension.

Yes No
Bathing Dressing
Toileting/Continence Walking
Meal Preparation
Yes No
SPOUSE INFORMATION

If the applicant is currently or was married:

Total Marriage(s)

CONTACT INFORMATION
Applicant Spouse Additional Contact
Information Regarding Referrals to Veterans Home Care ®

The “Aid and Attendance” pension is a benefit for non -service related disabilities, available to veterans or their surviving spouses who qualify. In order to qualify for the pension

  • The veteran must have served at least 90 days active duty in the military, with at least one day during wartime
  • The applicant must be at least 60% housebound (no longer driving), which will require certification by a licensed physician.
  • The applicant must meet certain income and asset limits

Applicants will need the following documentation to begin the application process:

  • Discharge papers (DD214)
  • Death Certificate with cause of death (if client is a surviving spouse)
  • Marriage Certificate or other proof of marriage, including date (if client is a married veteran or surviving spouse)

Please inform the prospective client that Veterans Home Care will need to ask personal questions regarding income and assets in order to prepare the application to the VA. Answers to all questions, including those that are financially related, will be kept confidential and will only be used to complete the application.

If the prospective client is unable or unwilling to answer income or asset - related questions, Veterans Home Care cannot assist him/her in applying for the “Aid and Attendance” VA pension.

Applicant Zip Code Needed

Please indicate the . Forms without this information will take longer to process.

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