Form 21-0779 for ALF

Discussion in 'Veteran Application' started by RGM, Jul 7, 2016.

  1. RGM

    RGM Newbie

    I want to start by thanking everyone here for all the great information, this process would be nearly impossible without your help.

    I'm just about ready to file for my dad. He's 89 and resting comfortably in a small ALF home. He had a degree of dementia before this all started in Dec 2015 but it has progressed since then after 2 separate falls and hip surgeries in 3 months. My mom at 87 is doing pretty well considering what she's dealing with.

    I'm finding that I am supposed to use the form 21-0779, but cross out all of the "Nursing Homes" and replace with ALF? Question 9 mentions the patient receiving "Skilled Nursing Care" or "Intermediate Nursing Care", and it says to check one. I'm pretty sure that neither apply so do I add "N/A", or should I give an explanation of the care.

    Aside from this form and the 21-2680, is there anything else that relates directly to his care that I need to provide?

    Thank you
  2. Kaylin

    Kaylin Hero Member Staff Member

    Thank you for the kind words, RGM!

    Yes, that is correct about the "nursing home" term on the 21-0779. You can put "N/A" if you'd like, and then explain either on that sheet or on the Statement in Support of Claim form 21-4138. You can use the 21-4138 for a vast number of things. Make sure you also get a Statement of Occupancy from his ALF, if you ask them they will know what it is. Any bank statements that show him paying for care are also encouraged.

    Make sure you mail everything return receipt and keep a copy of everything for yourself. Good luck!
  3. RGM

    RGM Newbie

    Thanks Kaylin and I just discovered a new question. I have read many times about the 3 offices that we should send all correspondence to. I have already sent in an Intent to file and a 21-0845 to the St Paul office. In the acknowledgement letter I received from them they said to send all correspondence to one of two addresses, one in Newnan GA, and the other in Janesville WI, where my acknowledgement letter was sent from. Is this something new?
  4. Kaylin

    Kaylin Hero Member Staff Member

    You're welcome!

    Well, the addresses for each of the 3 regions were changed recently. Since you already started your correspondence to the St. Paul office, you might just want to use that address. But here are the 3 new addresses based on your region:

    AL, AR, IL, IN, KY, LA, MI, MO, MS, OH, TN, WI

    Department of Veterans Affairs
    Claims Intake Center
    Attention: Milwaukee Pension Center
    PO Box 5192
    Janesville, WI 53547-5192

    AK, AZ, CA, CO, HI, IA, ID, KS, MN, MT, ND, NE, NM, NV, OK, OR, SD, TX, UT, WA, WY

    Department of Veterans Affairs
    Claims Intake Center
    Attention: St. Paul Pension Center
    PO Box 5365
    Janesville, WI 53547-5365

    CT, DC, DE, FL, GA, MA, MD, ME, NC, NH, NJ, NY, PA, PR, RI, SC, VA, VT, WV

    Department of Veterans Affairs
    Claims Intake Center
    Attention: Philadelphia Pension Center
    PO Box 5206
    Janesville, WI 53547-5206
  5. RGM

    RGM Newbie

    Thanks again, got it.
    Kaylin likes this.

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