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First Name
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Last Name
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Email
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Phone
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What timezone are you on?
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Eastern Standard Time
Mountain Standard Time
Central Standard Time
Pacific Standard Time
Alaska Standard Time
Hawaii-Aleutian Standard Time
Applicant is a...
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Surviving Spouse
Single Veteran
Married Veteran
Two Veterans Married to each other
Which war did the Applicant serve in?
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Vietnam War: 1955 - 1975
World War 2: 1941 - 1946
Gulf War: 1990+
Korean Conflict: 1950- 1955
Other
Is the Veteran receiving service connected disability compensation? (Not a requirement for Aid and Attendance eligibility)
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Veteran does not receive any disability compansation
Yes, 100% service connected
Yes, but less than 100% disability rating
No, Veteran is deceased
Unknown
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