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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in Line 1 with the name of the person receiving care services, which can be a veteran or their spouse.
- In Line 2, enter the name of the veteran for VA purposes. This is essential for identification.
- Line 3 requires the veteran's Social Security Number or VA Case Number. Ensure accuracy as this is crucial for processing.
- Complete Lines 4 through 10 with relevant details about the care service provider, including their address and contact information.
- Select the type of service offered by checking the appropriate box. This helps clarify the nature of care provided.
- Fill in any additional details regarding monthly charges and service duration as required in subsequent sections.
- Finally, ensure both the claimant and care provider sign at the end of the form to validate all information provided.
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