VA form 21-534 Section IX - Variable Assisted Living Costs

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I would like to apply for VA benefits before the end of this month (August 2010) for my Mother.  She entered an assisted living facility (ALF) on 8/17/10 of which she paid a prorated rate of $X for the 15 days in August.  For the 4 months September through December 2010, she will be paying a discounted rate of $Y and starting Janaury 2011, this rate will increase to $Z.

Should I list each of these as one line item each with column 40a show the the $X, $Y, and $Z amounts and in column 40c (Purpose) state this is for a specified period?

Since the sum of the ALF costs and the Medicare Deduction are greater than her income, do we need to enter any other costs?  The prescriptions are irregular and hard to project.