Aging with Grace Veterans Services

Questionnaire to Determine Eligibility for Veterans Pension or Death Pension

This eligibility request will help us more accurately determine your eligibility (or the eligibility of your loved one) for a veterans benefit. Please fill out each field as concisely as possible. Your information will remain private.

There is no obligation to you for filling out and submitting this form nor is there any charge for our informing you whether you are eligible or not.

If you prefer to return a completed form via fax or mail click here to download a printable version. You may return the form by fax to 1-215-565-2600 or mail to:

Aging with Grace™
187 Delaware Avenue
Oakhurst, NJ 07755
ATTN: VA Consultant

Inquirer Information for Notice of Eligibility and Probable Amount of the Benefit
	Name of Inquirer
Yes No	Is the Inquirer Power of Attorney for the Claimant?
	Relationship of Inquirer to Claimant
	Inquirer primary phone #
	Secondary phone #
Veteran's & / or Spouses Information
Veteran & Spouse Veteran Surviving Spouse	Who is applying for benefits? (Please mark only one)
	Veteran &/or Spouse's Name
	Age(s)
Single Married Widowed Divorced	What is their marital status? (Please mark only one)
Yes No	Is the claimant still driving?
	If applying for benefits as a surviving spouse, provide the name of the Veteran under the claim will be filed under.
Service Experience Mark X if conditions below apply Veteran was discharged from service with an honorable discharge, AND veteran served 90 days or more of active duty with at least 1 day during a period of war time. Veteran did not have to serve in combat conditions. Anyone who enlists after September 7, 1980, generally must have served at least 24 months or the full period for which called or ordered to active duty. Periods of war time are as follows:
	World War II: December 7, 1941 through December 31, 1946
	Korean Conflict: June 27, 1950 through January 31, 1955
	Vietnam Era: August 5, 1964 through May 7, 1975. War time for veterans who served “in country” before August 5, 1964 -- February 28, 1961 through May 7, 1975
	Gulf War: August 2, 1990 through a date to be set by law or Presidential Proclamation
	Date of entry into active duty
	Date of Discharge
Yes No	Did the Veteran serve at least 90 days of active military service?
Yes No	Was the Veteran discharged from the service honorably?
Monthly Income
	Social Security (Veteran)
	Pension (Veteran)
	Retirement Payments (Veteran)
	Disability Payments (Veteran)
	Interest/Dividends (Veteran)
	Other income (Veteran)
	Social Security (Spouse)
	Pension (Spouse)
	Retirement Payments (Spouse)
	Disability Payments (Spouse)
	Interest/Dividends (Spouse)
	Other income (Spouse)
	TOTAL MONTHLY INCOME (Spouse & Veteran)
Monthly Out of Pocket Medical Expenses
	Medicare Part B (Veteran)
	Medicare Supplement Premiums (Veteran)
	Medicare Drug Plan Premium (Veteran)
	Home Care Monthly Cost (Veteran)
	Adult Day Care Monthly Cost (Veteran)
	Assisted Living Monthly Cost (Veteran)
	Nursing Home Monthly Cost (Veteran)
	Any other recurring monthly costs (i.e., incontinence products; PERS, etc (Veteran)
	Medicare Part B (Spouse)
	Medicare Supplement Premiums (Spouse)
	Medicare Drug Plan Premium (Spouse)
	Home Care Monthly Cost (Spouse)
	Adult Day Care Monthly Cost (Spouse)
	Assisted Living Monthly Cost (Spouse)
	Nursing Home Monthly Cost (Spouse)
	Any other recurring monthly costs (i.e., incontinence products; PERS, etc (Spouse)
	TOTAL MONTHLY Out of Pocket Medical Expenses (Spouse & Veteran)
Assets / Net Worth
	Checking account (Veteran)
	Savings account (Veteran)
	CD’s (Veteran)
	Mutual funds/bonds/stocks (Veteran)
	Property other then residence (Veteran)
	Checking account (Spouse)
	Savings account (Spouse)
	CD’s (Spouse)
	Mutual funds/bonds/stocks (Spouse)
	Property other then residence (Spouse)
	TOTAL ASSETS & SAVINGS (Spouse & Veteran)
Medical Condition
	What is applicant’s current medical diagnosis?
Medical Need for a Rating Mark X if conditions below apply What activities of daily living does the claimant require assistance with:
	Bathing
	Dressing
	Medication Management/Reminders
	Toileting
	Meals
	Transferring
	Transportation
	Continence
Contact Information for Notice of Eligibility and Probable Amount of the Benefit
	Your Name
	Your Address
	Phone number(s) where we can call you
Evening Day	Best time to call?
	Or email where we can send you information
	We respect your privacy. Your information will not be given / sold to any other entity. Questions? Call 877-369-5418 AWG Veterans Benefits Consultants are private practitioners and not connected with the Department of Veterans Affairs. We comply with federal statutes and regulations governing the preparation, presentation and prosecution of any claim for veterans’ benefits with the U.S. Department of Veterans Affairs.