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Pre-Qualification Form

We are not a financial company. We do not charge fees to assist with applications, ever.

* Mandatory fields

First Name:

Last Name:

Address:

Home Number:

Email:

Email Confirmation:

Do you plan on living in assisted living or start home care services soon?

Yes No

If so, what do you plan on spending per month?

"We need an anwser here to understand medical expenses"

Type Of Care?

Were you referred by a sponsor? :

Yes No

List the assisted living or home care that referred you to us here:

For whom are you requesting this information:		Other? please specify
Are you currently in contact with an assisted living or home care agency?
We suggest you understand costs to better calculate if you will be eligible, can we put you in touch with some communities
In the area you are interested in to learn about costs?

Note!

You can only receive assistance if you were referred by a sponsor on our site, this may be by way of our office or putting you in touch with a county VA office in your town, however we would be more than happy to email you VA forms to file. The VA makes the final decision on all claims. Please visit our sponsors who support our program if you are in need of a quality eldercare provider here Click Here to find one.

Tell us about this person

First Name:

Age:

Marital Status:

Last Name:

Spouse's Name:

Age:

Current Address

City/State/Zip:

Current Resident Type:

Do you own or rent:

Monthly Payment:

Property Value:

Do you plan on living in assisted living soon?		If so, what do you plan on spending per month?
If you do not know about costs, please let our members help you with that by contacting you, is that okay?

Wartime Service Questionnaire

Veteran

Is the Veteran age 65 or older, or permanently disabled?

Did the Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?

Did the Veteran receive an honorable or general discharge?

Is the Veteran spending at least 75% of his/her monthly income on medical expenses? (including RX, health insurance, home health care, assisted living, and/or nursing home expenses)

Surviving Spouse of a Veteran

Is the un-remarried surviving spouse the last spouse of the Veteran at the time of his death?

Did the deceased Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?

Did the deceased Veteran receive an honorable or general discharge?

Is the surviving spouse spending 75% or more of his/her monthly income on medical expenses? (including RX, health insurance, home health care, assisted living and/or nursing home care)?

Health Questionnaire
Medical Diagnosis	Alzheimer's	Dementia	Other

*Select the activities of daily living this person requires assistance with:*
Dressing	Bathing	Toileting	Transferring	Continence	Meals	Medication Mgmt

Monthly Income/Expense Questionnaire
INCOME	VETERAN	SPOUSE
Social Security	$ *	$ *
Pensions	$ *	$ *
Interest Income	$	$
VA Retirment or Disability	$	$
Other	$	$
Total Monthly Income	$ *	$ *

EXPENSES
Medicare Part-B	$	$
Private Medical Insurance	$	$
RX Co-Pays	$	$
Doctor Visit Co-Pays	$ *	$ *
Private or Facility Health Care Cost	$	$
VA Health Benefits TRICARE	$	$
Total Monthly Medical Expenses	$	$

SAVINGS
Checking, savings, CDs	$	$
Stocks, bonds, mutual funds	$	$
IRA's	$	$
Other	$	$
Total Asset/Savings:	$ *	$ *

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