VA Assistance Intake Form

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VA Assistance Intake Form

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* Indicates required question

Name *

Your answer

Phone # *

Your answer

Last 4 of SS # *

Your answer

Email *

Your answer

Do you have your DD-214?

Yes

No

Clear selection

Are you currently receiving VA Benefits?

Yes

No

Clear selection

Have you signed up on Myhealthevet?

Yes

No

Clear selection

Have you signed up on eBenefits?

Yes

No

Clear selection

If Yes, what is your VA benefit rating

Your answer

What Presumptive are you needing help with?

Your answer

Submit

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