Eligibility Request

This eligibility request will help me more accurately determine your eligibility (or the eligibility of your loved one) for a veterans benefit. Please fill out each field as concisely as possible. Your information will remain private. Thank you.

Contact information
Name of Veteran:
Name of Veteran's spouse:
Name of person requesting information:
Email:
Phone #:
State:
Service during a period of war
Did you serve during period of war?: As a veteran, are you at least age 65, served at least one day during a period of war (wars are listed in the right column) and had 90 days of continuous military service with an honorable discharge?
Activities of Daily Living
Do you need assistance with any of the following ADLs?:	Medicating Bathing Dressing Toileting Transferring Eating
Assets
Estimated total assets (exclude home & car): (Checking, savings, stocks, investments, IRAs, other property, etc.)
Income
Estimated total annual income from all sources (If married include spousal income):
Un-reimbursed Expenses
List all unreimbursed, recurring health care expenses:
Assisted Living costs (per month):
Nursing Home costs (per month):
Home health care service (per month):
Health Insurance premium (per month):
Medicare premium (per month):
Regular (unreimbursed) prescriptions per month (verifiable through a pharmacy print-out):
TOTAL Monthly Deductible Expenses:

I respect your privacy. Your information will not be given/sold to any other entity.

World War II: December 7, 1941 through December 31, 1946

Korean War: June 27, 1950 through January 31, 1955

Vietnam War: August 5, 1964 (February 28, 1961, for veterans who served “in country” before August 5, 1964), through May 7, 1975

Gulf War: Aug. 2, 1990, through a date to be set by law of Presidential Proclamation.