Application Requirements

 

These are the documents that are required by the VA to process an application for the Non-Service Connected Pension with Aid & Attendance. Please do not send us any of these documents until eligibility is verified.

 

Discharge Papers

Form DD214 or WD AGO Form 53-55

  • Must be ORIGINAL or CERTIFIED
  • Can be any discharge other than dishonorable.
  • Must display raised seal or an authorized red, blue, or black stamp.
  • Date of entry, place of entry, date of separation, place of separation, and service number must all be present.

Request for Duplicate Discharge

Form to request a certified copy of discharge papers from the National Personal Records Center.

Standard Form 180

  • Only needed In the event that the original discharge papers...
    • Cannot be located
    • Are not legible
    • Are a copy without notarized seal or an authorized red, black, or blue stamp.
  • Directions
    1. Complete Section I as much as possible.
    2. Fill in YEAR(S) in Section II, Question 1.
    3. Complete Section III in it's entirety.
    4. Please ensure the Veteran or Surviving Spouse signs this form. Signature by a family member or Power of Attorney will delay the processing of this request
    5. Fax or Mail the form
      • Fax Directions
        • Fax to:
              National Personnel Records Center
              Fax: (314) 801-9195
        • * It is very important to call National Personal Records and confirm that your fax has been received - Phone: (314) 801-0800
      • Mail Directions:
        • Mail to:
              National Personnel Records Center
              1 Archives Dr.
              St. Louis, MO 63138
  • Note: between 16 and 18 million Military Personal Files were destroyed or damaged in the fire of 1973 at the St. Louis National Personnel Records Center. This fire destroyed about 80% of Army records from Nov. 1 1912 to Jan. 1 1960; and 75% of all Air Force records from Sep. 25. 1947 to Jan 1. 1964. For more information on the damage please refer to The 1973 Fire, National Personnel Records Center.
  • Download Request for New Discharge Form

Marriage License/Certificate

  • Must display the following:
    • Spouse's maiden name. (If not legible, please indicate on a separate sheet of paper.)
    • Date and Location of marriage.
  • Must be a copy.
  • For all previous marriage(s), a copy of each Marriage License or Marriage Certificate must be accompanied with a copy of either a Divorce Decree or a Death Certificate.

Proof of Income

  • All sources of income for both Veteran and Spouse need to be included.
  • Examples
    • Social Security Income
      • 1099 form, confirming annual income
    • Pension Statement - Enclosed with annual 1099 form
      • Explanation of pension fund
    • Interest Income
      • 1099 Form, confirming annual income
  • Must be copies.
  • Tax returns are not an acceptable proof of income.

Proof of Expenses

  • Facility Form - VA Form 21-0779 / Care Provider Statement
    • To be completed by all communities where Veteran and/or Spouse are currently living.
    • Required for all forms of care with the exception of in-home care.
    • Original signatures required
    • It is the Veteran's/Widow's/Power of Attorney's responsibility to:
    • Supply this Form to the Community
    • Download Facility Form  Download Care Provider Statement
  • In-Home Caregiver Forms
    • Required for all In-home caregivers and external caregivers at independent living communities.
    • Original signatures required
    • To be further discussed during our initial meeting.
    • For each individual applying for benefits, all caregivers must complete a copy.
      • If a caregiver is supplying care for a Veteran and Spouse, the caregiver must fill out a form for each person.
  • Health Care Insurance
    • Most recent invoice reflecting monthly/quarterly/yearly charges.
    • Must be a copy
  • Medicare - Social Security
    • Social Security Form 1099 - confirms annual income and Medicare annual deductions
    • Must be a copy
  • Medical Expenses NOT Accepted:
    • Prescriptions and Prescription copays
    • Hospital and Doctor copays

Proof of Assets

  • Online banking printouts are NOT ACCEPTABLE
  • Names and account numbers must be visible
  • Must be copies of all pages
  • Examples, but not limited to
    • Checking Account(s)
      • Copy of two (2) most recent bank statements
    • Money Market(s)
      • Copy of most recent statement
    • Saving Account(s)
      • Copy of most recent statement
    • Certificate Deposits (CD's)
      • Copy of most recent statement
    • Annuities, 401(k), Stocks, Bonds, IRA's, Brokerage Accounts, US Savings Bonds
      • Copy of most recent statement(s)
    • Life Insurance Policy(s)
      • Copy of most recent statement(s) listing death benefit and cash value
    • One voided check
      • Direct deposit of funds, (pending approval)
    • Property
      • Number of properties
      • Total estimated value of all properties
    • Tax Returns
      • Previous 3 year's tax returns

Medical Form

VA Form 21-2680 and VA Form 21-4138 - Doctor's Statement

  • A completed medical form is required for each person applying for benefits.
  • Entire form to be completed by Primary Care Doctor.
  • It is the Veteran's/Widow's/Power of Attorney's responsibility to:
  • Supply this form to Primary Care Doctor
  • VA Form 21-4138 - Doctor's Statement - There are several forms depending on your situation, please call the office to determine if this applies to you
  • See Activities of Daily Living footnote for more information
Download Medical Form

 

Self-Addressed, Stamped Envelope

For us to return your Original Discharge Papers


 

Other Required Information

  • Veteran's and Spouse's date of birth
  • Veteran's and Spouse's Social Security Number

 

Final Steps

  • Once all documents and forms have been gathered and completed, please call Billie Jo to review for completeness.
  • After the phone call with Billie Jo, please mail all documents to
    • Operation Veteran Benefits
    • 910 Sheraton Dr.
    • Suite 240
    • Mars, PA 16046
  • We cannot not accept faxed or emailed documents because original signatures are required for some forms.
  • Please feel free to call (866) 974-6737 (toll-free) or (724) 591-8475 if you have any further questions or concerns.

 

Activities of Daily Living

  • At least 3 required for claim. Defined as "Mean basic self-care activies such as, but not limited to the following:"
  • Hands-on assist with shower and dressing.
    • Help getting into and out of shower/tub
  • Frequent verbal direction due to diminished mental status.
    • Reminders to take shower
  • Incontinent of urine and bowels and needs assistance for hygiene and assessment and cleaning
    • Uses Depends or other form of adult diapers
  • Assistance with ambulation
    • Help with walking from one position to another, such as getting in and out of bed or from chair to bathroom.
  • Meals - needs help eating
    • Need of help cutting food
  • Speech/communication deficiency which inhibits claimant's ability to convey needs.
  • Supervision of medication which includes ordering, controlling and assistance with self-administration
    • Reminders to take medications

Instrumental Activities of Daily Living (IADLs)

  • Helps support the claim, defined as "Mean independent living actvities such as, but not limited to the following:"
  • Shopping
  • Food Preparation
  • Daily Housekeeping
  • Transportation to Doctor's Appointments, Shopping, Etc.
  • Laundry
  • Managing Finances
  • Handling Medications
  • Using the telephone
  • Transportation for Non-medical purposes

Operation Veteran Benefits, the individuals, and services listed on this web site are not affiliated with the US Department of Veterans Affairs. Only individuals on this site who are accredited by the VA are involved in the assistance of preparation and presentation of a claim for veteran benefits.