Income & Asset Information Please Complete All Fields – If not applicable, please use N/A Main Contact Name *Veteran or claimant name *Main Contact Email *Relationship to Veteran/Claimant *Marital Status of Veteran/Claimant *MarriedDIvorcedWidowedNever MarriedBest Contact Tel. Number for Main Contact *Do not include spaces or hyphensAge of Veteran or Claimant Dates of Active Service World War II – 12/07/1941 – 12/31/1946Korea – 06/27/1950 – 01/31/1955Vietnam – 08/05/1964 – 05/07/1975Persian Gulf – 08/02/1900 – TBDHonorable/General Discharge YesNoBranch of Military NavyArmyAir ForceCoast GuardMerchant MarinesDo you have the original or certified copy of the veteran’s discharge paperwork? YesNoMonthly cost of care in Assisted Living or In-Home Social Security for Veteran (GROSS) Other Pensions or Income for Veteran – Please list source and monthly amount i.e. Teamsters Military Income – Retirement/Disability Long Term Care Policy – Veteran IRA/RMD – Veteran Savings Account Balance CD – Current Value Rental Income Real Estate – Do you own any of the following: ResidenceRentalsLandManufactured HouseOther medical expenses such as supplemental health care/vision/dental/prescription Social Security for Spouse/Surviving Spouse (GROSS) Other Pensions or Income for Spouse/Surviving Spouse – Please list source and monthly amount i.e. Teamsters Death Indemnity Compensation for Surviving Spouse Long Term Care Policy – Spouse/Surviving Spouse IRA/RMD – Spouse/Surviving Spouse Checking Account Balance Stocks/Bonds/Mutual Funds – Please list source and Value Is there a trust in place? YesNoIf there is a trust please list ALL assets the trust currently owns including real estate Anything else we should know? WebsiteSubmitShare this:TwitterFacebookLinkedInLike this:Like Loading...
