Senior Veteran
Aid & Attendance Application for Illinois
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Forms Needed:

Do not file any forms directly with the VA. Find a VA approved "Advocate" if something goes wrong the Advocate can help you.

Veterans who file without an advocate average thousands of dollars less per year than Veterans that have an advocate. We have an Advocate in mind for you (we are volunteers for this program)!

We know the VA Advocates that have the best service in Illinois. Call us before you file.
1-847-462-8266

Contact Information

Fill this form out and we can get you the correct information or call Silver Connections  at

847-303-9602
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State: IL We can only Help IL Veterans at this time
Call your Local American Legion for more information
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Comments:


Thomas J. O'Dea
WWII Marine

You Will Need the Following

•Discharge separation papers DD-214
  or standard form 180. Now online @ http://www.archives.gov/veterans/evetrecs/index.html
•
•Social security award letter JAN
•Proof of bills
•Physician statement VDVA 10 required in Illinois

Surviving spouse
needs marriage certificate & death certificate

Blank Form

MEDICAL STATEMENT FOR CONSIDERATION OF AID & ATTENDANCE

**(Please circle the appropriate answer and explain each in detail.)**

 

 

RETURN ADDRESS:

 
 VA FILE NO.__________________________    
                               

VETERAN’S NAME: _______________________________________________  

                                     Last  

 

CLAIMANT’S NAME:____________________________________________________________

                                      Last                                                         First                                                  Middle

 

1.  Complete Diagnosis:______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

2.  Is the claimant able to walk unaided?                          Yes                             No

Explanation:_______________________________________________________________________

_________________________________________________________________________________

 

3.  Is the claimant able to feed him/herself?                       Yes                             No

Explanation:_______________________________________________________________________

_________________________________________________________________________________

 

4.  Does the claimant need assistance in bathing and tending to other hygiene needs?         Yes           No

 

5.  Is the claimant able to care for the needs of nature?      Yes                             No

Explanation:_______________________________________________________________________

_________________________________________________________________________________

 

6.  Is the claimant confined to bed?                                    Yes                            No

Explanation:_______________________________________________________________________

_________________________________________________________________________________

 

 

7.  Is the claimant able to sit up?                                        Yes                            No

Explanation:_______________________________________________________________________

_________________________________________________________________________________

 

 

 

 

 

 

 


































VDVA FORM 10

                                                                                                                        Page 2

 

8.  Is the claimant blind?                                  Yes                                        No

Corrected Vision:              L_____________________      R_____________________

Explanation:______________________________________________________________________

_________________________________________________________________________________

9.  Is the claimant able to travel?                        Yes                                       No

Explanation:_______________________________________________________________________

_________________________________________________________________________________

10.  Can the claimant leave home without assistance?         Yes                       No

(If yes, how far can he/she go?(List distance)

Explanation:_______________________________________________________________________

11.  Does the claimant require nursing home care?              Yes                      No

Explanation:_______________________________________________________________________
 

12.  In your opinion, are there other pertinent facts which would show the claimant’s need for aid and attendance?______________________________________________________________________________

 

**  If possible, please attach copies of office or hospital records concerning the claimant’s recent medical history.

 

 

I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT.

PHYSICIAN’S NAME & ADDRESS

(Please type or print)

________________________________                    _____________________________________

                                                                                               (Examining Physician’s Signature)

________________________________                               

 

________________________________

 

 

**Billing Information:

All expenses incurred as a result of this exam are the responsibility of the veteran/claimant. 
Direct billing to this agency is not authorized.

 

 

 
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