VFA & VFF Questionnaire

VFA & VFF Questionnaire

Questionnaire: Let's get started

Please fill in the Veterans & Families of America (VFA) Questionnaire. This questionnaire is needed to help us in determining eligibility for VA benefits for home care, assisted living, or nursing home. We need you to complete the following questionnaire.

VFA & VFF Initial Worksheet

Name of person completing this worksheet
Name of person completing this worksheet
First
Last
Address
Address
City
State/Province
Zip/Postal
Name of Veteran
Name of Veteran
First
Last
Veteran Status
Name of Spouse
Name of Spouse
First
Last
Spouse Status

The following information is necessary to determine eligibility for VA Benefits.

(Please mark all that apply.)

Service & Health Qualifications

Honorable discharge?
Have DD-214?

Veteran Health Information

Current Life expectancy
Assistance Needed

Spouse Health Information

Current Life expectancy
Assistance Needed

Monthly Medical Care expenses (Veteran &Spouse)

$.00
$.00
$.00
$.00
$.00
$.00

Total Gross Monthly income (Veteran & Spouse)

$.00
$.00
$.00
$.00
$.00

ASSETS (Veteran & Spouse)

Do you own a home?
$.00
$.00
$.00
$.00
$.00
$.00
$.00
$.00
$.00
(Do not include the Home)
Do you intend to apply for Medicaid?
Have you purchased a Burial final expense plan?
Have you gifted or transferred assets in the past 36 months?
Have you updated your Will in the past 5 years?
Have you updated your Power of Attorney in the past 5 years?

Note, this is not the VA application. Please answer all the questions then hit the submit button to send the questionnaire to us.

After we receive the questionnaire, will contact you to review your information.

We greatly appreciate your service to our country.