DEATH PENSION

FOR WIDOW(ER)SIN A NURSING HOME

THIS IS NOT THE ACTUAL APPLICATION, IT IS ONLY A WORKSHEET. AFTER YOU HAVE COMPLETED THE WORKSHEET, PLEASE CALL THE ONEIDACOUNTYVETERANS’ SERVICE OFFICE AT (715) 369-6127 TO MAKE AN APPOINTMENT SO THE CLAIM CAN BE COMPLETED.

Veteran’s full name (including maiden name, if applicable):

______

Veteran’s SSN: ______

Spouse’s full name (including maiden name, if applicable):

______

Spouse’s date of birth: ______Spouse’s SSN: ______

Previous marriage information: This information is not optional. If you do not knowexact dates, you must provide at least the month and year of previous marriages and their ending dates. Your marriage certificate to the veteran and his/her death certificate are required to accompany the claim.

Veteran’s previous marriages:

Date of
Marriage / Place of
Marriage / To Whom Married
(First, MI, Last name) / Date
Ended / Place
Ended / How
Ended

Your previous marriages:

Date of
Marriage / Place of
Marriage / To Whom Married
(First, MI, Last name) / Date
Ended / Place
Ended / How
Ended

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Net worth from all sources:

Cash, Bank Accounts, Certificates
of Deposit (CDs)
IRAs, Keogh Plans, etc.
Stocks, Bonds, Mutual Funds
Value of Business Assets
Real Property (not your home as long as you are living in it)
All Other Property

Monthly income: This is gross household income from all sources. If you receive Social Security, include the amount you pay for Medicare even though it’s taken out before you receive your Social Security.

Social Security
U.S. Civil Service
U.S. Railroad Retirement
Military Retired Pay
Black Lung Benefits
Supplemental Security Income
(SSI) and Public Assistance
Other income received monthly
Source: ______

Expected income for the next 12 months (put the annual amount, not the monthly amount):

Gross wages and salary (from
employment)
Total interest and dividends (if you have interest bearing assets, you
must put an amount here)
Other expected income
Source: ______

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Direct deposit information:

 Checking Account number: ______

OR

 Savings Account number: ______

Financial institution: ______

Routing number: ______

Note: The Department of Treasury has mandated that all recurring federal benefits be administered through either Electronic Funds Transfer (EFT) or Direct Express Debit MasterCard. Paper checks are not authorized.

Medical expenses: To determine eligibility for this pension benefit the VA looks at your gross household income from all sources and they onlyadjust it for the medical expenses you pay out-of-pocket that they can reasonably presume will recur every month. These are things like Medicare and supplementary health insurance. Co-pays for doctor visits and medications are generally not accepted because payments like that change from month-to-month. If you would still like to claim expenses like that, you must furnish a complete description of the expense and the reason you feel it should be allowed. The first time you apply for this benefit, you can claim the funeral expenses you paid for your spouse. A copy of the funeral bill and receipt showing it was paid must be provided with the claim. The liability you pay each month to the nursing home is also an allowable expense but the amount you list as a medical expense must coincide with the VA form 21-0779 the billing office at the nursing home fills out and signs on your behalf. A copy of that form is attached and must be filled out by the nursing home before your claim can be completed.

Purpose / Amount Paid
By You / Date Paid / Name of
Provider / For Whom Paid
Example:
Medicare / $1158.00 / 01/2011-
12/2011 / Social Security / Self
Example:
Funeral Expenses / $7200.00 / 2/10/2011 / Smith Funeral Home / Spouse

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