Attendant Affidavit PDF Details

In this form, the attendant must indicate which services they provide, such as assistance with bathing, standing and sitting, getting in and out of bed, eating, walking, dressing and undressing, taking medication, or other services. They must also provide their contact information, sign the form, and certify under penalty of law that the information provided is true and correct.

The claimant (veteran) must also sign the form, attesting to the accuracy of the information provided by the attendant. If the claimant signs with a mark, it must be witnessed by two witnesses, who must also sign and date the form. This form serves as a legal document that may be used as evidence when applying for VA benefits or assistance related to the veteran's care.

QuestionAnswer
Form NameVeterans Affair Attendant Affidavit
Form Length1 pages
Fillable?Yes
Fillable fields28
Avg. time to fill out5 min 55 sec
Other namesattendant affidavit form va, va attendant affidavit, attendant affidavit fillable, va attendant affidavit form pdf

Form Preview Example

 

 

 

 

 

 

ATTENDANT AFFIDAVIT

 

 

 

 

 

 

Re:

___________________________________

 

 

 

 

 

 

 

Veteran’s Name – Last, First, Middle

 

 

 

 

 

 

 

__________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA Claim or Social Security Number

 

 

 

 

 

 

 

__________________________________

 

 

 

 

 

 

 

Claimant’s Name

 

 

 

 

 

 

 

__________________________________

 

 

 

 

 

 

 

Claimant’s Address (Street)

 

 

 

 

 

 

 

__________________________________

 

 

 

 

 

 

 

City, State and Zip Code

 

 

 

 

My name is _________________________, and I provide health care for the above named claimant.

The services which I provide are:

 

 

 

 

Yes

No

Assistance with bathing

 

Yes

No

Standing and sitting

 

Yes

No

Getting in and out of bed

 

Yes

No

Eating

 

Yes

No

Walking

 

Yes

No

Dressing and undressing

 

Yes

No

Taking medication

 

Other: (Please describe)

______________________________________________________________________________________

_____________________________________________________________________________________________

_______________________________________________________________________________

For these services, I am paid by the claimant _____________ per week / month / year (please circle only one).

I began employment on ___________________________.

__________________________________________________________

Signature of provider

__________________________________________________________

Street Address

__________________________________________________________

City, State, and Zip Code

__________________________________________________________

Phone number (including area code)

I CERTIFY, under the penalty of law, that the above information is true and correct, that I do pay the above referenced sitter the amount listed for the services listed. (If claimant signs with his/her mark, the mark must be witnessed by two witnesses.)

Signature: ____________________________

Date: ________________________

Witness:

____________________________

Date: ________________________

Witness:

____________________________

Date: ________________________

How to Edit Veterans Affair Attendant Affidavit Online for Free

Due to the objective of making it as easy to operate as possible, we set up this PDF editor. The procedure of completing the va attendant affidavit is going to be very simple should you keep to the next actions.

Step 1: Select the button "Get Form Here" on the webpage and press it.

Step 2: Right now, you can begin editing your va attendant affidavit. The multifunctional toolbar is available to you - insert, erase, adjust, highlight, and conduct other sorts of commands with the content in the form.

For every single part, fill out the content requested by the software.

veterans affair attendant affidavit pdffiller com gaps to fill in

Include the requested particulars in the Yes, Yes, Yes, Yes, Eating, Walking, Dressing and undressing, Taking medication, Other Please describe, For these services I am paid by, I began employment on, and Signature of provider Street area.

veterans affair attendant affidavit pdffiller com Yes, Yes, Yes, Yes, Eating, Walking, Dressing and undressing, Taking medication, Other Please describe, For these services I am paid by, I began employment on, and Signature of provider  Street blanks to fill out

You have to put down specific details inside the box I CERTIFY under the penalty of law, Signature, Date, Witness, Date, Witness, and Date.

stage 3 to filling out veterans affair attendant affidavit pdffiller com

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