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Identify and Submit a Lead

Use the "Basic Qualifications" link to learn what a person needs to qualify as an Aid and Attendance pension candidate.

To have a list of questions to use in intake conversations, use the "Prescreening Questions."

Have a question or need help? Contact Cheri McElroy at cheri@patriotpension.com or call 254-315-5325

Online Form

Printable Form

Basic Qualifications

Prescreening Questions

1. Identify

2. Submit

After you determine that the lead is a good candidate, please submit the information through our online form below.

Alternatively, you can print the form, fill it out and mail back to me (instructions on the printout).

Agency Submission Form

Please use the following questions to let us know about your lead. If you do not have an answer, please write "N/A." You can add additional comments at the bottom of the form if needed.

CONTACT INFO

REFERRING HOME CARE AGENCY CONTACT INFORMATION

THE VETERAN OR SURVIVING SPOUSE'S INFORMATION

PRIMARY CONTACT PERSON (if applicable)

MILITARY

The Vet must have served at least one day during wartime, and 90 active days total. Which period(s) did the Veteran serve?

WWII

7 Dec 1941 - 31 Dec 1946

Korean Conflict

27 June 1950 - 31 Jan 1955

Vietnam Era

28 Feb 1961 - 7 May 1975 - Served in the Republic of Vietnam (South Vietnam)

Vietnam Era

5 Aug 1964 - 7 May 1975

Gulf War

2 Aug 1990 - present

Dates of veteran's service (can be an estimate)

Was Veteran dishonorably discharged?

Medical

Does the lead need help with at least two ADLs?

List health needs, including any diagnoses and ADLs the lead needs help with:

Is the lead 100% disabled?

Money

Does the lead most likely have less than $129,000 in assets (excluding home and one vehicle)

List any government assistance the lead is already receiving (e.g., Social security, VA pension, food stamps)

Do you feel that the lead's medical expenses will most likely exceed his/her income?

Any additional Information helpful in screening this lead

BONUS ROUND - completely optional

Feedback to help make this form or the submission process better

Thanks for submitting!