The Jacks Law Group - Secure VA Benefits Intake Form

The Jacks Law Group - Secure VA Benefits Intake Form

Complete this confidential intake to provide your veteran, claim, family, medical, and authorization details for processing.
Page 1 - Veteran & Claimant Identification
Are you the Veteran?
Relationship to Veteran
Veteran Full Name

First NameMiddle NameLast Name
Social Security Number
VA File Number (IF KNOWN)
Date of Birth

MonthDayYear
Date
Place of Birth
Gender
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Page 2 - Military Service History
Branch of Service

Other
Service Number / DoD ID
Periods of Service
Character of Service
Rank / Grade at Separation
Former Prisoner of War?
Exposure / Environment
Exposure Details
DD-214 / Service Records (IF YOU HAVE IT/THEM)

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Additional Entry / Separation Details
Military Occupational Specialty (MOS) / Rate / AFSC
Unit / Command at Separation
Page 3 - Marital History
Current marital status

Other
Current spouse full name

First NameMiddle NameLast Name
Current spouse date of birth

MonthDayYear
Date
Date of marriage

MonthDayYear
Date
Place of marriage
Type of marriage
Is current spouse a veteran?
Current spouse address if different

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Veteran's ALL Prior/Ex-Spouses (click +Add for each one)
Current Spouse's ALL Prior/Ex-Spouses (click +Add for each one)
Spouse details are only required if currently married or if current spouse information is applicable.
Page 4 - All Dependents
ALL Children, Step-Children & Adopted Children (click +Add for each one)
Upload birth and custody documents

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Page 5 - Employment & Unemployability
Current employment status

Other
Date last worked

MonthDayYear
Date
Employer name
Employer address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Job title
Hours worked per week
Current or last earnings
Job duties and physical demands
Reason employment ended or reduced
Have you applied for Social Security disability benefits?
Page 6 - Finances
Veteran Monthly Income
Spouse Monthly Income
Other Household Monthly Income
Bank Account Value
Cash on Hand Value
Investment Value
Real Estate Value
Other Assets Value
Out-of-Pocket Medical Expenses
Page 7 - Disabilities & Medical History
Claimed Conditions, Onset, and Service Connection
All Treatment Facilities
Upload Medical Records

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Page 8 - Insurance & Special Benefits
Do you have any health insurance coverage?
Health insurance provider name
Policyholder name
Medicare coverage
Have you applied for or used VA adapted housing benefits?
Have you applied for or used the VA Caregiver Program?
Are you currently eligible for CHAMPVA?
CHAMPVA-related details or comments
Page 9 - Survivor/Burial
This section applies only if you are completing survivor or burial information. If not applicable, you may leave the fields blank.
Date of Death

MonthDayYear
Date
Place of Death
Burial Details
Burial Expenses (USD)
Memorial Type
Inscription Text
Page 10 - Authorizations & Signature
Acknowledgement of Representation by The Jacks Law Group
Authorization to Share Information with Third Parties
Alternate Signer Full Name
Alternate Signer Authority
Printed Name
Date

MonthDayYear
Date
E-Signature
Should be Empty:

The Jacks Law Group - Secure VA Benefits Intake Form

Page 1 - Veteran & Claimant Identification

Page 2 - Military Service History

Page 3 - Marital History

Page 4 - All Dependents

Page 5 - Employment & Unemployability

Page 6 - Finances

Page 7 - Disabilities & Medical History

Page 8 - Insurance & Special Benefits

Page 9 - Survivor/Burial

Page 10 - Authorizations & Signature