Aid and Attendance Interest FormPlease submit this form if you are interested in applying for VA Aid and Attendance benefits for home care services on your or someone else's behalf.Your Name*This is your information. If you are submitting for someone else, we will get their information below First Last Your Email* Your Phone*Are you applying for yourself or for someone else?* Self Someone else, who is a Veteran or Surviving Spouse Your relationship with the person you are referring? Should we follow up with you? Yes No, please contact the Veteran/Surviving Spouse Name of the Veteran or Surviving Spouse First Last Veteran/Surviving Spouse Email Veteran/Surviving Spouse PhoneAddress where service needs to be provided* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth of Veteran/Surviving Spouse MM slash DD slash YYYY War during which Veteran served? WWII Korean Vietnam Services needed? (Select all that apply) Select All Bathing Dressing Toileting Walking Meal Prep Light Housekeeping Additional CommentsConsent*Life Foundation Home Care is not affiliated with the Department of Veteran Affairs or Veterans Home Care. Life Foundation Home Care is an independent Home Care agency providing home care to Veterans and Surviving Spouses. Submitting this form doesn't make you eligible for VA benefits. I understand
