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Qualification Application
Please fill out the following questions to the best of your ability. If you get stuck, please continue through the assessment. One of our qualified specialists will get back to you.
10
Questions
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1
Your Name
*
This field is required.
First Name
Last Name
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2
Your Contact Details
*
This field is required.
Please enter your email
Please enter your phone
Phone Call
Email
Phone Call
Email
Prefered method of contact
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3
Type of Applicant
Veteran
Veteran and Spouse
Spouse of Veteran
Two Veterans married
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4
Applicant's Information
Applicant's Name
Applicant's City
Applicant's State
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5
Select which war(s) the Veterans served in and if the veteran served at least 90 days of Active Duty. Select all that apply.
World War II (December 7, 1941 – December 31, 1946)
Korean Conflict (June 27, 1950 – January 31, 1955)
Vietnam Era I (February 28, 1961 - August 4, 1964 for Veterans who served inside the Republic of Vietnam)
Vietnam Era II (August 5, 1964 - May 8, 1975)
Gulf War (August 2, 1990 – through a future date to be set by law or Presidential Proclamation)
90 Days of Active duty
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6
Do you need help at home with any of the following activities of daily living?
Walking
Grooming
Sitting / Standing
Bathing
Toileting
Eating
Making Meals
Taking Medication
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7
Are assets less than $131,000? This does not include primary residence and primary vehicle. Assets do include land, minerals, rental, all financial accounts.
Yes
No, stop application
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8
Monthly Income
Monthly income below $1200
Monthly income between $1200 - $1900
Monthly income between $1900 - $2500
Monthly income between $2500 - $3500
Monthly income between $3500 - $4400
Monthly income over $4400
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9
Does the Veteran or Veteran Spouse receive any compensation from the VA?
No
Yes, less than $500
Yes, less than $1200
Yes, more than $1200
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10
Referring Organization and Individual
Referring Organization (Example: Visiting Angels Wichita Falls)
Referral Name
Referral's Phone Number
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