VA Benefits

Today's Date

Name*

First Last

Address*

Street Address City State ZIP Code

DOB*

Phone Number*

Branch of Service*

Dates of Service

Start of Service

End of Service

Character of discharge

Reason for Your Visit or Call?

Financial Need?*

If yes please answer the next three questions

Yes
No

Is your income lower than or close to $2081 a month if single or $2818 as a couple?

Yes
No

Do you have less than $8,400 in assets if single or $16,600 as a couple?

Total assets include all bank, checking, savings, retirement accounts, cash value of life insurance and real estate, not including the value of your primary residence or vehicle

Yes
No

Do you pay for medical expenses? (Premiums, prescription co-pays, etc.)

Yes
No

File VA Disability Claim?

Yes
No

Other Veterans Benefits

Yes
No

Are you in the VA medical System?

Yes
No

Do you have a VA disability?

Yes
No

If yes what is your %

Have you visited this office before?

Yes
No

Name of Service Officer

Comments

Cape Cod District

Department of Veterans’ Services

Cape Cod District Department of Veterans Services’ — Intake Form

Reason for Your Visit or Call?