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VA Intake Evaluation Form
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Confidential Benefits Evaluation Intake Form
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Primary contact name
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Relationship to the claimant
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Phone
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Email
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Address
Tell us about Recipient (Potential Claimant)
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Name
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DOB
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Phone Number
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E-mail
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Address
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City
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State
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Zip code
Are you currently:
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Select Option
Married
Divorced
Widow
Single
If you are currently married, do you live with your spouse?
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Yes
No
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(If not, please explain why)
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Spouse's name
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Is/was a veteran?
Yes
No
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DOB
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Date of marriage
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Veteran’s date of death
If you are the widow/widower of a veteran, did you live continuously with the veteran from the date of marriage until the date of death?
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Yes
No
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(If no, why not?)
If you are the widow/widower of a veteran, did you remarry after the veteran passed away?
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Yes
No
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How many children do you have?
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What are their names, ages and city/state of residence?
Health Information
In your opinion, would a doctor certify that you need assistance with daily living?
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Yes
No
What types of activities do you need assistance with?
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ADLs
Bathing
Dressing
Eating
Transferring
Toileting
Walking
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IADLs
Meals
Medication
Transportation
Security
Other
Other condition
Severe cognitive impairmen
Legally blind
Facility/Provider Information
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Is anyone currently receiving medical/facility care?
Veteran
Spouse
Both
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Are you currently in a facility?
Yes
No
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If yes, which type of facility are you in?
Assisted living
Nursing/Rehab
Independent living
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What is the name of your facility?
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What is your monthly cost for this facility?
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Do you currently live at home?
Yes
No
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Are you receiving at home care?
Yes
No
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If so, what date did you begin receiving care?
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Who provides your at-home care?
Medical Expense Information
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Do you have long-term care insurance?
Yes
No
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If yes, does it help pay for your current care?
Yes
No
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Monthly cost of your LTC?
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What amount does it cover daily?
Do you have medical health insurance deductions taken from your social security check?
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Yes
No
If yes, please provide the monthly amount that is deducted from your check:
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Part B
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Part D
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Other
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Do you have supplemental health insurance?
Yes
No
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Monthly cost of that supplemental insurance?
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What is the name of the supplemental health insurance provider?
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Does your spouse have long-term care insurance?
Yes
No
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If yes, does it help pay for his/her current care?
Yes
No
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Monthly cost of spouse LTC?
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What amount does it cover daily?
Does your spouse have medical health insurance deductions taken from his/her social security check?
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Yes
No
If yes, please provide the monthly amount that is deducted from his/her check:
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Part B
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Part D
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Other
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Does your spouse have supplemental health insurance?
Yes
No
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Monthly cost of that supplemental insurance?
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What is the name of the supplemental health insurance provider?
Is the Veteran or Spouse currently receiving Medicaid?
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Self
Yes
No
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Spouse
Yes
No
Military Service Information
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Are you the veteran?
Yes
No
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Or the surviving spouse?
Yes
No
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In what branch of the military did the veteran serve?
Did the veteran serve in active duty during a declared state of war?
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Yes
No
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What dates (month/year) and during which war time (WWII, Korea, etc.) did the veteran serve?
Did the veteran receive an honorable discharge?
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Yes
No
Have you ever filed a claim with the VA?
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Yes
No
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Do you have the discharge papers?
Yes
No
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File/Claim number?
Are you currently receiving a pension or compensation benefits from the VA?
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Yes
No
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If yes, what is the monthly amount you receive?
Financial Information
Income:
Please list the
GROSS monthly income
for both the veteran and spouse (if not applicable put 0).
Social Security income
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Veteran
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Spouse
Pension
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Veteran
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Spouse
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Source
Interest/Dividend/RMD
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Veteran
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Spouse
Military Retirement
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Veteran
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Spouse
Other
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Veteran
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Spouse
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Source
Assets:
Please list all assets that make up your net worth in the appropriate space below (if not applicable put 0).
Cash/Non-Interest Accounts
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Veteran
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Spouse
Interest Bearing Accounts
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Veteran
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Spouse
Stocks, Bonds, Mutual Funds
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Veteran
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Spouse
IRA/Retirement Accounts
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Veteran
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Spouse
Annuities
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Veteran
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Spouse
Money Titled in a Trust
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Veteran
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Spouse
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Have any savings bonds been redeemed in the last year?
Yes
No
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How much redeemed?
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Any life insurance benefits received?
Yes
No
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How much insurance benefit received?
Have you transferred or gifted assets after October 17, 2018?
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Yes
No
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If so, please explain
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Do you have a trust?
Yes
No
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Is it revocable or irrevocable?
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Do you have a life insurance policy?
Yes
No
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What is the cash value of the policy?
Do you and/or your spouse currently own your primary residence?
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Yes
No
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What is the size of the lot on which it sits?(Square Feet)
Could any part of the lot be sold without selling the residence?
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Yes
No
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What is the value of this property?
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Current Mortgage Balance?
Do you currently have a reverse mortgage on this property?
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Yes
No
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If so, what amount?
Do you currently own any other property or real estate?
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Yes
No
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If yes, please describe the property type and the value
Do you plan on selling either the primary residence or other real estate in the near future?
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Yes
No
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Date signed
I certify that the information provided is true and correct to the best of my knowledge.
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