Test - Veterans Angels Inc.

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1Claimant Information

2Military Service

3Discharge & Aid

4Living Situation

5Family Contact

6Contact Details

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The Claimant is a… (Claimant is Veteran or Surviving Spouse) *

Married Veteran (Veteran with Spouse or Dependent)
Single Veteran
Un-remarried Surviving Spouse of a Qualified Veteran

Q: Is the Veteran age 65 or older, OR, if under age 65, totally and permanently disabled? *

(Spouse does not need to be over 65) Applies only to Married Veterans.

Q: Was the Claimant married to the veteran for at least ONE year? *

Q: Was the claimant married to the veteran at the time of his/her death? *

Based Upon Your Response… Unfortunately at this time, based upon the response submitted, it appears the claimant may not be eligible to apply. If you feel you answered one of the questions incorrectly, you can start from the beginning. You may also call our toll-free number at 1 (888) 319-1117 for further assistance.
Please note, these eligibility questions are for your information only. The Department of Veterans Affairs makes the final decision as to whether the claim is viable.

Q: Did the Veteran serve at least 90 days of active military service with at least ONE day during a wartime period?*

- World War II – December 7, 1941 thru December 31, 1946*

- Korean Conflict – June 27, 1950 thru January 31, 1955

- Vietnam Era – August 5, 1964 thru May 7, 1975**

- Persian Gulf War – August 2, 1990 thru a date to be set by law or Presidential Proclamation

**** If the veteran was in service on December 31, 1946, with continuous service before July 26, 1947, this is considered World War II service.

**** Veterans who were "In Country", (Vietnam), prior to August 5, 1964 would use the following Official Wartime Periods for the Vietnam Era:

February 28, 1961 thru May 7, 1975.

Checkboxes *

Veteran did not need to serve in combat

Q: Did the veteran have an honorable or general discharge under honorable conditions? *

Q: Does the Claimant require the “Aid & Attendance” of another person on a regular basis and is unable to protect themselves from the hazards of their daily environment? *

* This diagnosis must be provided by a physician and might include, but is not limited to, issues regarding mobility, dressing, memory issues, communication, social interaction, and psychiatric impairments.

Q: Is the Claimant (or spouse) currently (or in the near future) residing in an assisted living home, group home, adult day care OR receiving care from an in-home care agency or a family member other than their spouse? *

Q: Is the Claimant currently (or in the near future) residing in an assisted living home, group home, adult day care OR receiving care from an in-home care agency or a family member? *

***Please Note
Additional Information is Needed - Please Continue filling out the questionare
A Confidential Information form will be provided to determine Eligibility to apply.

Claimant’s First Name *

Claimant’s Last Name *

Claimant’s Date of Birth *

Mobile *

Home *

Email *

Street Address *

City *

State *

Zip Code *

Person who we contact *

Email *

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Your Relationship To Claimant *

Mobile *

Home

Referral Source

Referral Source *

Referral Name

Referral Email

Message