NAVF INTAKE FORM INTAKE – National Association of Veterans & Families

1Notice

2Point of Contact Information

3Veteran & Spouse Info

4Service & Health Info

5Asset Information

6Income Information

7Expense Information

8Wrap-up Question

Notification

This Intake Form is not a VA application. Please answer all the questions and then submit. After we receive the questionnaire, we will contact you to review your information.

Point of Contact Information

Name of Person filling out this form *

First

Last

Relationship to applicant

Email *

Phone *

Veteran & Spouse Information

Name of Veteran *

First

Last

Address

Address Line 1

City

State

Zip Code

Age if Living

Name of Spouse

First

Last

Age if Living

Service & Health Information

(Please mark all that apply.)

Do you have a DD-214 or other proof of service? *

Date Service Started

Date Service Ended

Who is applicant?: Veteran and/or Spouse *

Veteran
Spouse

Assistance Needed

Dementia/Alzheimer’s

Other health conditions

Asset Information

ASSET INFO FOR VETERAN & SPOUSE (Asset & Income information is Required by the VA)

Checking, Savings, Money Market *

CDs

Stocks, Bonds and/or mutual funds

Do you have an IRA or 401K? *

If so, what is the value

TOTAL Assets (Veteran & Spouse)

Do you own a home? *

Do you own other property?

Other land or rental property (value)

Have you purchased a funeral plan? *

Have you gifted or transferred assets in the past 36 months *

Income Information

Total Gross Monthly Income (Veteran & Spouse)

Social Security Income Veteran

Social Security Income Spouse

Monthly retirement for Veteran

Monthly retirement for Spouse

Req. Min Distribution (Annual divided by 12 = monthly RMD)

VACP (Veteran's Compensation)

Other Income and Source

TOTAL MONTHLY INCOME (Best Estimate for Veteran and Spouse) *

Expense Information

Monthly Medical Care Expenses (for Veteran & Spouse)

Does applicant live at home? *

Who is providing care?

Are they currently in rehab or hospital? *

Is applicant living in or planning on moving to an assisted living or independent living facility? *

Name of Assisted Living or Independent Living facility (important)

Assisted Living costs

Independent Living cost

Home healthcare Cost

Long Term Care Insurance premium

Wrap-up Question

How did you learn about NAVF? *

Please tell us who (Person or Care Facility)