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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 last updated: October 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.

Downloadable PDF

Download VA Form 21-0779 (PDF)
  • 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. 

    Download VA Form 21-2680 (PDF)
  • If you need help with daily activities, or you’re housebound, learn about these benefits and if you qualify.