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Person to contact

1. Please enter the information
for the person to contact.

Name
Last Name
✓ Valid number ✕ Invalid number
Preferred Contact is:

VETERAN OR SURVIVING SPOUSE

2. Please enter the information indicated below.

First Name
Last Name
✓ Valid number ✕ Invalid number

VETERAN OF SURVIVING SPOUSE

3. Provide the address of the veteran or surviving spouse:

Postal Code

PERSON TO CONTACT

4. Are you a provider or senior care professional referring a client/patient?

Are you a provider or senior care professional referring a client/patient?
✓ Valid number ✕ Invalid number
Referral Source Zip Code:

MILITARY SCREENING QUESTIONS

5. Are you, or your loved one, a veteran or the spouse of a wartime veteran

Are you, or your loved one, a veteran or the spouse of a wartime veteran.
Are you, or your loved one, a veteran or the spouse of a wartime veteran. (Surviving spouse must have been married to the veteran at least 1 year and at time of veteran's death.)

MILITARY SCREENING QUESTIONS


6. Did the veteran serve during a wartime period and receive an honorable or general discharge?

Did the veteran serve during a wartime period and receive an honorable or general discharge?

MEDICAL SCREENING QUESTIONS


7. Does the veteran or spouse have a medical condition and need assistance with activities of daily living?

Does the veteran or spouse have a medical condition and need assistance with activities of daily living?
Help with bathing, dressing, using the bathroom,
meal preparation, moving about safely, etc.

MEDICAL SCREENING QUESTIONS


If eligible for pension, do you want to use it to cover the cost of in home care?

If eligible for pension, do you want to use it to cover the cost of in home care?
If eligible for pension, do you want to use it to cover the cost of in home care?

MEDICAL SCREENING QUESTIONS


9. Does the veteran receive a service-connected disability pension? Does the spouse receive DIC (disability indemnity compensation) from the VA?

Does the veteran receive a service-connected disability pension? Does the spouse receive DIC (disability indemnity compensation) from the VA?
Does the veteran receive a service-connected disability pension? Does the spouse receive DIC (disability indemnity compensation) from the VA?


Does the single veteran receive over $1041/month from the VA?
Does the single veteran receive over $1041/month from the VA?
Does the surviving spouse receive over $603/month from the VA?
Does the surviving spouse receive over $603/month from the VA?
Does the married veteran receive over $1,141/month from the VA?
Does the married veteran receive over $1,141/month from the VA?
Does either of the married veterans receive over $1,141/month from the VA?
Does either of the married veterans receive over $1,141/month from the VA?

MONETARY SCREENING QUESTIONS


10. Does the single wartime veteran have a monthly income at or less than $4,000?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


10. Does the surviving spouse have a monthly income at or less than $3,500?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


10. Does the couple have a monthly income at or less than $5,000?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


10. Does the couple have a monthly income at or less than $6,000?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


11. Does the veteran, spouse or the couple have a total net worth at or less than $155,000?

Does the veteran, spouse or the couple have a total net worth at or less than $155,000? (The primary residence or vehicle are not counted as an asset, however, savings accounts, checking accounts, IRA’s, stocks, bonds are counted.)
The primary residence or vehicle are not counted as an asset, however, saving accounts, checking accounts, IRA's, stocks, bonds are counted.

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1
2
3
4
5
6
7
8
9
10
11

Person to contact

1. Please enter the information
for the person to contact.

Name
Last Name
✓ Valid number ✕ Invalid number
Preferred Contact is:

VETERAN OR SURVIVING SPOUSE

2. Please enter the information indicated below.

First Name
Last Name
✓ Valid number ✕ Invalid number

VETERAN OF SURVIVING SPOUSE

3. Provide the address of the veteran or surviving spouse:

Postal Code

PERSON TO CONTACT

4. Are you a provider or senior care professional referring a client/patient?

Are you a provider or senior care professional referring a client/patient?
✓ Valid number ✕ Invalid number
Referral Source Zip Code:

MILITARY SCREENING QUESTIONS

5. Are you, or your loved one, a veteran or the spouse of a wartime veteran

Are you, or your loved one, a veteran or the spouse of a wartime veteran.
Are you, or your loved one, a veteran or the spouse of a wartime veteran. (Surviving spouse must have been married to the veteran at least 1 year and at time of veteran's death.)

MILITARY SCREENING QUESTIONS


6. Did the veteran serve during a wartime period and receive an honorable or general discharge?

Did the veteran serve during a wartime period and receive an honorable or general discharge?

MEDICAL SCREENING QUESTIONS


7. Does the veteran or spouse have a medical condition and need assistance with activities of daily living?

Does the veteran or spouse have a medical condition and need assistance with activities of daily living?
Help with bathing, dressing, using the bathroom,
meal preparation, moving about safely, etc.

MEDICAL SCREENING QUESTIONS


If eligible for pension, do you want to use it to cover the cost of in home care?

If eligible for pension, do you want to use it to cover the cost of in home care?
If eligible for pension, do you want to use it to cover the cost of in home care?

MEDICAL SCREENING QUESTIONS


9. Does the veteran receive a service-connected disability pension? Does the spouse receive DIC (disability indemnity compensation) from the VA?

Does the veteran receive a service-connected disability pension? Does the spouse receive DIC (disability indemnity compensation) from the VA?
Does the veteran receive a service-connected disability pension? Does the spouse receive DIC (disability indemnity compensation) from the VA?


Does the single veteran receive over $1041/month from the VA?
Does the single veteran receive over $1041/month from the VA?
Does the surviving spouse receive over $603/month from the VA?
Does the surviving spouse receive over $603/month from the VA?
Does the married veteran receive over $1,141/month from the VA?
Does the married veteran receive over $1,141/month from the VA?
Does either of the married veterans receive over $1,141/month from the VA?
Does either of the married veterans receive over $1,141/month from the VA?

MONETARY SCREENING QUESTIONS


10. Does the single wartime veteran have a monthly income at or less than $4,000?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


10. Does the surviving spouse have a monthly income at or less than $3,500?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


10. Does the couple have a monthly income at or less than $5,000?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


10. Does the couple have a monthly income at or less than $6,000?

10. Does the single wartime veteran have a monthly income at or less than $4,000?(Required)

MONETARY SCREENING QUESTIONS


11. Does the veteran, spouse or the couple have a total net worth at or less than $155,000?

Does the veteran, spouse or the couple have a total net worth at or less than $155,000? (The primary residence or vehicle are not counted as an asset, however, savings accounts, checking accounts, IRA’s, stocks, bonds are counted.)
The primary residence or vehicle are not counted as an asset, however, saving accounts, checking accounts, IRA's, stocks, bonds are counted.