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Pre-Qualification Form

Please fill in the details.

* Mandatory fields

Inquirer Information

First Name:

Last Name:

Address:

Home Number:

Email:

Email Confirmation:

Does the senior 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?

Type of Application

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?

Need help with your pre-qual? Call us direct at 877-312-8959 or email us at veteranspensionplanners@gmail.com for help now.

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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