Apply for VA Pension

Accredited Agent: Steve Dabbs (Accred #21130) • steve.dabbs@gmail.com • 480-967-8477

Fill out below. We’ll generate your full VA claim package instantly.

1. Veteran Information

Last Name * First Name * Middle Initial Social Security # (no spaces) * Date of Birth * Zip Code * Service Number (usually SSN) * Permanent Address * City, State * Phone * Email

2. Emergent Claim? (Check if applies)

TERM (Terminally ill) SERW (Seriously injured) FINH (Financial hardship) HOME (Homeless) AGE (>85) HONR (Medal of Honor)

3. Service Information

Entered Active Duty * Separated from Active Duty * Branch of Service

4. Marital Status

Spouse Name Spouse SSN Spouse DOB

5. Income & Net Worth

Monthly Income (SSA, pension, etc.) Net Worth (Bank, car, savings – exclude home) Need Aid & Attendance? Yes No

VA Pension Claim Input Form

VA Pension Claim Application

Fill out this form to generate your VA claim documents. All data is local—nothing is sent until you submit.

Centralized Intake Coversheet

Veteran Last Name: * Veteran First Name: * Veteran Middle Initial: Veteran Social Security #: * Veteran Zip Code: * Claims Agent's Contact Email: * Claims Agent's Phone: * Veteran's Service Number: * Number of Pages (Including Coversheet): *

List Forms Included (Select all that apply)

VA 21-0845 Authorization to Disclose
VA 21-22a Appointment of VSO
VA 21-2680 Examination for Aid and Attendance
VA 21-4138 Statement in Support of Claim
VA 21P-0969 Income and Asset Statement
VA 21P-527EZ Application for Veterans Pension
VA 21P-534EZ Application for Survivors Pension
VA 21P-8416 Medical Expense Form
Care Expense Form
Supporting Documents
Other: Spouse's Name (if Married): Spouse's SS#: Spouse's DOB: Permanent Address for Claim: * City: * State: * ZIP: * Phone: * Email: *

VA Form 21-4138: Statement in Support of Claim

Veteran/Beneficiary's Name (First, Middle Initial, Last): * Veteran's Social Security Number: * VA File Number (If applicable): Veteran's Date of Birth (MM/DD/YYYY): Veteran's Service Number (If applicable): Telephone Number (Include Area Code): E-Mail Address (Optional): Mailing Address:

Remarks (Statement in Support of Claim): * Remarks (Continued): Signature of Veteran/Beneficiary: * (Type or sign) Date Signed (MM/DD/YYYY): *

VA Form 21P-527EZ: Application for Veterans Pension

Section I: Veteran's Identification Information

Veteran's Name (First, Middle Initial, Last): * Veteran's Social Security Number: * Veteran's Date of Birth (MM/DD/YYYY): * Have you ever filed a claim with VA? Yes No VA File Number (If applicable):

Section II: Veteran's Contact Information

Mailing Address: *

Telephone Number (Include Area Code): * Veteran's E-Mail Address (Optional):

Section III: Veteran's Service Information

Other Name(s) You Served Under (If None, leave blank): Date Initially Entered Active Duty (MM/DD/YYYY): * Final Release Date From Active Duty (MM/DD/YYYY): * Your Service Number: * Branch of Service: * Army
Navy
Air Force
Coast Guard
Marine Corps
Space Force
USPHS
NOAA
Place of Your Last Separation: * Have You Ever Been a Prisoner of War? Yes No

Dates Confinement Started (MM/DD/YYYY): Dates Confinement Ended (MM/DD/YYYY):

Section IV: Pension Information

Are you over the age of 65 or have you been determined to be disabled by Social Security Administration? Yes No Are you medically incapable of working? Yes No Do you live in a nursing home? Yes No

Does Medicaid cover all or part of your nursing home costs or have you applied for Medicaid? Yes No

Are you claiming Special Monthly Pension because you need the regular assistance of another person, have severe visual impairment or are generally confined to your immediate premises? Yes No Have you received treatment from a VA medical center? Yes No

Specify Facility:

Have you recently received treatment from any federal medical facilities (Military base, etc.)? Yes No

Specify Facility:

Section V: Employment History

Are you currently employed? Yes No

What kind of work are you currently doing? What many hours per week do you average?

When did you last work (MM/DD/YYYY): How many hours per week did you average? What was your job title? What kind of work did you do?

Section VI: Marital Status

What is your marital status? * Married Separated Not Married (Widowed or Never Married)

Spouse's Current Legal Name (First, Middle Initial, Last): Spouse's Birth Date (MM/DD/YYYY): Spouse's Social Security Number: Date and Place of Marriage (MM/DD/YYYY): Type of Marriage: Ceremonial Other (Specify) Is your spouse also a Veteran? Yes No Spouse's VA File Number (If any): If you are separated, tell us the reason (Illness, work, etc.): Spouse's Mailing Address (If separated):

How much do you contribute monthly to your spouse's support? (If separated):

Section VII: Prior Marital History

Tell us about your and your spouse's previous marriages. If none, skip.

Veteran's Prior Marriages

Who were you married to? (First, Middle Initial, Last): How did your previous marriage end? Death Divorce Other (Specify) Dates of Previous Marriage Start (MM/DD/YYYY): End (MM/DD/YYYY): Place of Marriage (City and State or Country): Place of Marriage Termination:

Spouse's Prior Marriages

Who was your spouse married to? (First, Middle Initial, Last):

Section VIII: Dependent Children

How many dependent children live with you?

Do all children not living with you reside at the same address? Yes No Name of Custodian (If children not living with you): Custodian Address:

Section IX: Questions Regarding Income and Assets

Do you and your dependents have over $25,000 in assets (not including primary residence)? Yes No

Estimate total value of assets:

Did you or dependents transfer any assets in the last 3 years? Yes No Do you own your primary residence? Yes No Is the lot size over 2 acres? Yes No

Value of land over 2 acres: Is the land marketable? Yes No

Do you have more than 4 sources of income? Yes No

Income Source 1

Who is the income recipient? Veteran Spouse Child (Specify) Type of Income: Social Security Interest/Dividends Civil Service Pension/Retirement Other (Specify) Income Payer (Name of business, etc.): Current Gross Monthly Income:

Section X: Information About Your Unreimbursed Medical Expenses

Are you or dependents claiming unreimbursed medical expenses? Yes No

Expense 1

Whose expenses were paid? Veteran Spouse Child (Specify) Name of Provider and Type of Care: If in-home care, rate per hour: Hours worked per week: Type: Care Facility In-Home Care Attendant Provider Start Date (MM/DD/YYYY): End Date (MM/DD/YYYY or No End Date): No End Date Payment Frequency: Monthly Annually Amount You Pay:

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