Country and Columbia Cottages - Veteran's Assistance Prequalifiation

Veteran's Assistance Prequalification

Country Cottage Columbia Cottage

Veteran's Assistance

Prequalification Form

Please fill out all required fields below and press the Submit button when you are finished. Someone will be in contact with you shortly.

Inquirer Information
* indicates required field

First Name*
Last Name*
Phone Number*
E-mail Address*
Address*
City*
State*			Zip*
For whom are you requesting this information?
Does he or she currently live in a Nursing Home or Assisted Living?
How were your referred to us?

Veteran and Spouse Information
Please fill this section out even if you are inquiring for yourself.
* indicates required field

First Name*
Last Name*
Address*
City*
State*			Zip*
Age
Spouse's Name
Current Residence Type
Property Value
Does this person rent or own?
Monthly Payment
Does this person plan on living in an Assisted Living community soon?
If so, what do you plan on spending per month?

Wartime Service Questionnaire
* indicates required field

Veteran		Surviving Spouse of Veteran

Is the Veteran age 65 or older, or permanently disabled?		Is the unremarried surviving spose the last Spouse of the Veteran at the time of his death?

Did the Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?		Did the deceased Veteran serve at least 90 days in active service, with at least 1 day during a wartime period?

Did the Veteran receive an honorable or general discharge?		Did the deceased Veteran receive an honorable or general discharge?

Health Questionnaire

Medical Diagnosis: Alzheimer's Dementia Other

Please select the activities of daily living that this person requires assistance with:

Dressing	Bathing	Toileting	Transferring
Continence	Meals	Medications

Monthly Income/Expense Questionnaire
* indicates required field

Income	Veteran	Spouse

Social Security	$*	$*
Pensions	$*	$*
Interest Income	$	$
VA Retirement or Disability	$	$
Other	$	$
Total Monthly Income	$*	$*

Expenses

Medicare Part-B	$	$
Private Medical Insurance/ Medicare Supplement	$	$
Senior HMO	$	$
Monthly Home Care Costs	$	$
Monthly Cost of Living	$	$
Cost of Long Term Care Insurance	$	$
Total Monthly Medical Expenditures	$*	$*

Savings

Checking, Savings, CDs	$	$
Stocks, Bonds, Mutual Funds	$	$
IRAs	$	$
Other Savings	$	$
Total Assets/Savings	$*	$*

Cottage Assisted Living

Corinth, MS

Lawrenceburg, TN

Cottage Assisted Living