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|\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT NEED  \u003Cbr>FOR REGULAR AID AND ATTENDANCE   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| INSTRUCTIONS:Before completing this form,read the Privacy Act and Respondent Burden on page 4.Use this  \u003Cbr>form to determine eligibility for aid and attendance or housebound benefits.For more information,you can contact  \u003Cbr>us online through Ask VA:https:/www.va.govlcontact-us/ask-va/introduction.Ask us a question online or call  \u003Cbr>us toll-free at 1-800-698-2411(TTY:711).VA forms are available at www.va.govlvaforms.   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| SECTION I:VETERAN'S IDENTIFICATION INFORMATION   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| NOTE:You may complete the form online or by hand.If completing by hand,print neatly and legibly in ink,and completely fill in each applicable check box to  \u003Cbr>help expedite processing of the form.   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 1.VETERAN/BENEFICIARY'S NAME(First,Middle Initial,Last)   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 2.SOCIAL SECURITY NUMBER   |  |  |  |  |  |  |  |  |  | 3.VAFILE NUMBER(If applicable)   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 4.VETERAN'S SERVICE NUMBER(lf applicable)   |  |  |  |  |  |  |  |  |  | 5.DATE OF BIRTH(MM/DD/YYYY)  \u003Cbr>一  \u003Cbr>-   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| SECTIONII:CLAIMANT'S IDENTIFICATION INFORMATION   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 6.CLAIMANT'S NAME(First,Middle Initial,Last)   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 7.CLAIMANT'S SOCIAL SECURITY NUMBER   |  |  |  |  |  |  |  |  | 8.RELATIONSHIP OF CLAIMANT TO VETERAN  \u003Cbr>□SELF  \u003Cbr>□PARENT  \u003Cbr>□SPOUSE  \u003Cbr>□CHILD   |  |  |  |  |  |  |  |  | 9.CLAIMANTS DATE OF BIRT  \u003Cbr>一  \u003Cbr>一   |  |  |  |  |  |  |  |  | H(MMDDYYYY)   |\n| -  \u003Cbr>一   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 10.MAILINGADDRESS(Number and street or rural route,P.O.Box,City,State,ZIP Code and Country)   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 11.TELEPHONE NUMBER(Optional)(Include Area Code)  \u003Cbr>Enter International Phone Number (If applicable)  \u003Cbr>一  \u003Cbr>一   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 12.EMAIL ADDRESS (Optional)      lagree to receive electronic correspondence from VAin regardsto my claim   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| SECTION IⅢ:CLAIM INFORMATION   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 13.SELECT ONE OF THE FOLLOWING BENEFITS(Choose one)  \u003Cbr>Special Monthly Compensation(SMC)-Veterans and surviving spouses or parents who are eligible to receive VA compensation due to a service-related disability  \u003Cbr>or death and require aid and attendance of another person to perform personal functions required in everyday living such as bathing,feeding,dressing,attending to  \u003Cbr>th","cbCaituSt2fRvT7R","https://ap.wps.com/l/cbCaituSt2fRvT7R","pdf",1307705,"English","# Instructions\n## Veteran/Beneficiary Identification Information\n## Claimant Identification Information\n## Claim Information\n## Hospitalization Questions","[{\"question\":\"What is this VA form for?\",\"answer\":\"It determines eligibility for VA aid and attendance or housebound benefits for qualifying veterans and certain eligible claimants.\"},{\"question\":\"Which benefit types can be selected on the form?\",\"answer\":\"The form provides a choice between Special Monthly Compensation (SMC) and Special Monthly Pension (SMP), based on eligibility criteria described in the instructions.\"},{\"question\":\"How does the form address hospitalization?\",\"answer\":\"It asks whether the veteran/claimant is hospitalized and, if yes, requests the admission date, hospital name, and hospital address.\"}]","EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT NEED FOR REGULAR AID AND ATTENDANCE | 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