Married Veteran (Veteran with Spouse or Dependent)Single VeteranUn-remarried Surviving Spouse of a Qualified Veteran
[group group-single-married]
[group group-married]
(Spouse does not need to be over 65)
[/group] YesNo [/group]
[group group-not-qualified]
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.
[/group]
[group group-claimant-spouse]
YesNo
YesNo [/group]
[group group-military-service]
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.
[group group-discharge-honorable]
[group group-aid-attendance]
* 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.
[group group-assisted-living]
[group group-50k]
A Confidential Information form will be provided to determine Eligibility to apply.
[group group-qualified]
First Name *
Last Name *
Email *
Home Phone *
Cell Phone
Work Phone
Mailing Address *
City *
State *
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
ZIP Code *
Relationship To Claimant *
—Please choose an option—Family MemberSelfPower of AttorneyLegal GuardianOther
[group group-claimant-relationship]
Claimant’s First Name
Claimant’s Last Name
Claimant’s Date of Birth *
Referrals are vital to our ability to continue helping veterans and their families. Please take a moment to tell us how you learned about Veterans Angels, Inc. Also, we would like to send a “Thank You!” email to whomever referred you, if possible.
Referral Source:
—Please choose an option—FamilyCo-worker/ColleagueFriendAssisted Living CommunityGroup HomeMedical CommunitySearch EngineRadioPlacement AgencySocial WorkerOther
Referral Name:
Referral Email:
