Application Form

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Information About Person Completing Request

First Name*

Last Name*

Relationship to Veteran*

Email Address*

Phone Number*

Information About Surviving Spouse (Only if Veteran is Deceased)

Surviving Spouse First Name

Surviving Spouse Last Name

Death Date of Veteran

Surviving Spouse Married to Veteran at His/Her Death?

Yes No

Information About Wartime Veteran

Veteran First Name*

Veteran Last Name*

Branch of Service*

Did the Veteran serve for at least 90 days of active duty?

Yes No

Did the Veteran receive a dishonorable discharge?

Yes No

Is the Veteran at least 65 years of age or totally disabled?

Yes No

Please indicate at least one day of wartime service by selecting all that apply:

World War II (Wartime Service)

World War II: Dec 7, 1941 thru Dec 31, 1946 N/A

Korean Conflict (Wartime Service)

Korean Conflict: June 27, 1950 thru January 31, 1955 N/A

Vietnam War (Wartime Service)

Vietnam War: In Country from Feb 28, 1961 thru Aug 4, 1964 Vietnam War: Otherwise Aug 5, 1964 thru May 7, 1975 N/A

Gulf War (Wartime Service)

Gulf War: Aug 2, 1990 thru future date N/A

By submitting this form you agree to the following: I would like to consider applying for the wartime aid and attendance pension. APSC has permission to save my data & contact me via phone or email to discuss this matter further. I understand there is no obligation to retain APSC's services, nor does APSC charge for application assistance.

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