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Benefits Questionnaire
Benefits Questionnaire
1. Are you a veteran, spouse or dependent of a veteran, or on active duty?
Veteran
Spouse or Dependent
Active Duty
2. Are you male or female?
Male
Female
3. Do you or the veteran have a VA service-connected disability rating?
Yes
No
4. If any of the following apply to you, select YES:
Served in Vietnam or the Gulf Wars, or
Exposed to radiation, or
Developed Amyotrophic Lateral Sclerosis (ALS), or
Were a prisoner of war.
Yes
No
5. Do you have limited or no income?
Yes
No
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