Texas veterans commission nursing home statement form 2026

1. Click ‘Get Form’ to open the Texas Veterans Commission Nursing Home Statement Form in the editor.
2. Begin by entering the veteran's name, ensuring it is provided whether the statement is for the veteran or their widow. Fill in the Claim # or SSN for identification.
3. Next, input the name of the Assisted Living Facility and the claimant's details, including their address, telephone number, and mailing address.
4. Specify the date of admission and include the facility's license number along with city, state, and zip code.
5. In the 'Statement of Charges' section, enter the amount of recurring gross daily charges for assisted living care and any amounts paid that are not reimbursed.
6. Complete the Claimant Certification by signing and certifying that expenses are paid from personal funds. If applicable, ensure two witnesses sign if using a mark.
7. Indicate if assistance is required by checking appropriate boxes regarding disabilities and level of care needed.
8. Add any additional remarks as necessary before signing off with the date and signature of an Assisted Living Facility Administrator or Agent.

Start filling out your Texas Veterans Commission Nursing Home Statement Form online for free today!