Veterans Benefit
Pre-Qualification Form
You may be eligible for a Veterans Benefit that many
people don’t even know exists.
Did you serve the United States military? Or are you the surviving spouse of a veteran? If so,
you may be eligible for a little known Veterans Benefit that can help you pay for high-cost, nonreimbursed monthly medical expenses.
It's the Non-Service Connected Disability Pension Benefit, also known as the Veterans Aid and
Attendance Benefit, and it can provide additional monthly income up to $2,053 a month.
The benefit can help pay for such out-of-pocket medical expenses as adult day services, home
care, family caregivers, in-home safety equipment, assisted living, nursing home care, Medicare
premiums, or medical co-pays.
What does it take to qualify?
This benefit is not based on service-related injuries and allows for veterans and single,
surviving spouses with low incomes or high care expenses to receive additional support. For
a veteran or surviving spouse to be eligible, the veteran:



Must have served at least 90 days of active duty, with at least one day during a
period of war
Must have been honorably discharged
Must meet medical and financial requirements set by the Veterans Administration
for veterans or for single, surviving spouses
Maximum monthly pension benefits for 2014
If applicants are qualified, the maximum monthly pension amounts are:
o A veteran with no spouse or dependent children — $1,732
o A married veteran and spouse — $2,053
o Single, surviving spouse of a veteran — $1,113
The application process for the Veterans Aid and Attendance Benefit is complicated. Before
you submit a claim for benefits, it is strongly recommended that you seek the guidance of a
professional accredited by the Department of Veterans Affairs.
©2013 SH Franchising, LLC
Updated 05/17/13
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Veterans Benefit
Pre-Qualification Form
VA Benefit for Aid and Attendance Eligibility
Self-Pre-Qualification Form
Please answer the questions below to help Senior Helpers determine if the veteran or single,
surviving spouse may be deemed eligible by the Veterans Administration for Aid and
Attendance, Housebound Benefits, or Basic Pension.
Veteran Name:
Age:
Marital Status:
Living or Deceased:
Spouse’s Name:
Living or Deceased:
Phone:
Email:
Current Address:
City:
ST:
☐Own
Current Residence Type:
Monthly Payment:
Zip:
☐Rent
Property Value:
Are you selling your home?
☐Y ☐N
Have you recently moved assets?
☐Y ☐N
Do you drive?
☐Y ☐N
Does the veteran/spouse need assistance with the activities of daily living?
☐Y ☐N
Did the veteran receive an honorable or general discharge?
☐Y ☐N
Did the Veteran (living or deceased) serve at least one day during the following
periods with 90 days of continuous military services?
 World War II – December 7, 1941 through December 31, 1946
 Korean War – June 27, 1950 through January 31, 1955
 Vietnam War – august 5, 1964 (February 28, 1961, for veterans who served “in
country” before August 5, 1964) through May 7, 1975
 Gulf War – August 2, 1980 through a date to be set by law or presidential
proclamation
☐Y ☐ N
©2013 SH Franchising, LLC
Updated 05/17/13
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Veterans Benefit
Pre-Qualification Form
List Medical Diagnosis:
☐Alzheimer’s
☐Dementia
☐Other:
Select the activities of daily living for the person requiring assistance:
☐Dressing
☐Bathing
☐Toileting
☐Continence
☐Meals
☐Medication Management
Determining Income Eligibility
Monthly Income/Expenses Questionnaire
A. Income
Veteran
Spouse
Social Security
$
$
Pensions (Include VA retirement/Disability Income)
$
$
Interest Income/IRA Distribution
$
$
Other (civil service/rental income/annuity payment, etc.)
$
$
TOTAL MONTHLY GROSS INCOME
$
$
B. Out-of-Pocket Expenses
Veteran
Spouse
Medicare Part B and/or Part D
$
$
Private Med. Insurance (Med Supplement/LTC/Cancer/etc.)
$
$
Rx Insurance Plan or Rx Co-Pay
$
$
Doctor Visit Co-pay
$
$
Private, Home Care or Facility Health Care Cost
$
$
TOTAL MONTHLY OUT OF POCKET EXPENSES
$
$
C. Assets/Savings
Veteran
Spouse
Checking, Savings, CDs
$
$
Stocks, Bonds, Mutual Funds
$
$
IRAs
$
$
Trusts
$
$
Other (Life Insurance, Annuities, Non primary home)
$
$
TOTAL ASSETS/SAVINGS
$
$
©2013 SH Franchising, LLC
Updated 05/17/13
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Veterans Benefit
Pre-Qualification Form
Please list all unreimbursed, reoccurring health care expenses below to determine your
countable income. A zero “countable income” may result in full Aid and Attendance.
D. Reoccurring Medical Expenses
Veteran
Spouse
Assisted living cost (per month)
$
$
Nursing home costs (per month)
$
$
Home care service (per month)
$
$
Health insurance premium (per month)
$
$
Medicare premium (per month)
$
$
Regular monthly or annual (unreimbursed) prescriptions
(per month and verifiable through a pharmacy printout)
$
$
Doctor Visit Co-pay (per month)
$
$
TOTAL MONTHLY REOCCURING MEDICAL EXPENSES
$
$
Countable Income Calculation
Total Monthly Reoccurring Medical Expenses (D)
$
Multiply by 12 to get total Annual Expenses
$
Total Annual Income (A)
$
Total Countable Income (subtract your total annual expenses from your total
annual income) (A — D)
$
Disclaimer: The purpose of this letter is to educate you about Veterans Administration (“VA”) home health care
benefits that may qualify for. Our office can educate you about the benefits available and assist you in completing
and submitting the benefits application to the VA. Please fill out the enclosed form so that we can make an initial
determination regarding your potential qualification for the VA benefits. Our desire is to help you receive the VA
benefits that you deserve and have earned for your service to our country.
We are NOT the VA, nor are we in any way affiliated with the VA. If you wish to contact the VA you can do so by
calling 800-827-1000 or visiting them at www.va.gov. NONE OF OUR SERVICES ARE INTENDED AS LEGAL OR
FINANCIAL ADVICE. IF YOU ARE SEEKING LEGAL OR FINANCIAL ADVICE PLEASE CONSULT YOUR
LEGAL/FINANCIAL ADVISOR.
Senior Helpers – North Houston
14405 Walters Road
Suite 390
Houston, TX 77014
Main 281 919 1876
Fax 832 218 2043
©2013 SH Franchising, LLC
Updated 05/17/13
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