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Forgotten Income for Forgotten People

Do you Qualify for the Improved Pension Benefit,    and/or one of the two add-ons:   

"Housebound" or "Aid and Attendance"

Please fill out the form below and use the submit button at the bottom to get it to us quickly.

All information provided is confidential and will not be used for any other purpose.

We receive many inquiries every day. Therefore, it might take us a few days to respond to your form. You may leave a message and we will respond anywhere from 1 to 24 hours. Or you can email us at  info@GBAUSA.org. 

On this form, Please state if you are currently working with one of our Analysts.

Thank you for the opportunity to serve you,
Government Benefits Analysts, Inc.
* Mandatory fields

First Name: *      
Last Name: *   Contact Phone Number: *
Address:   Email: *
      Email Confirmation: *
City:     Zip:
For whom are you requesting this information?
Other? please specify
Are you currently Living in a Nursing Home or Assisted Living Center?    
How were you referred to us, or, List the Facility where you are currently located?:

First Name: Age: Marital Status:    
Last Name: Spouse's Name: Age:
Current Address
City/State/Zip:
Current Resident Type: Do you own or rent:  
Monthly Payment: Property Value:
 
Do you plan on living in assisted living soon? If so, what do you plan on spending per month?


Is the Veteran age 65 or older, or permanently disabled?
Did the Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?
Did the Veteran receive an honorable or general discharge?
 
Is the un-remarried surviving spouse the last spouse of the Veteran at the time of his death?
Did the deceased Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?
Did the deceased Veteran receive an honorable or general discharge?
Medical Diagnosis Alzheimer's Dementia Other 
Select the activities of daily living this person requires assistance with:
Dressing Bathing Toileting Transferring Continence Meals Medication Mgmt
INCOME VETERAN SPOUSE
Social Security $ * $ *
Pensions $ * $ *
Interest Income $ $
VA Retirement or Disability $ $
Other $ $
Total Monthly Income $ * $ *
EXPENSES
Medicare Part-B $ $
Private Medical Insurance/ Medicare Supp. $ $
Senior HMO $ $
Monthly Home Care Costs $ * $ *
Monthly Cost of Facility $ $
Cost of Long Term Care insurance $ $
Total Monthly Medical Expenses $ $
SAVINGS
Checking, savings, CDs $ $
Stocks, bonds, mutual funds $ $
IRA's $ $
Other  
$ $
Total Asset/Savings: $ * $ *

Click the Submit button to send the form.     

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