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About VA Form 21-0779

Form name: Request for Nursing Home Information in Connection with Claim for Aid and Attendance
Related to: Disability
Form revision date: September 2023

When to use this form

Use VA Form 21-0779 if you’re a resident of a nursing home and you're providing supporting information for your claim application for VA Aid and Attendance benefits.

Download form

Download this PDF form and fill it out. Then submit your completed form on this page. Or you can print the form and mail it to the address listed on the form.

VA Form 21-2680

Form name: Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

Use VA Form 21-2680 to apply for Aid and Attendance benefits that will be added to your monthly compensation or pension benefits. 

  • If you need help with daily activities, or you’re housebound, learn about these benefits and if you qualify.