OMB control number
Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)
OMB 2900-0652 · VA.
OMB 2900-0652
VA Form 21-0779 is used to gather the necessary information to determine eligibility for pension and aid and attendance based on being in a nursing home. This form also requests information on Medicaid status and nursing home care charges, so VA can determine the proper rate of payment. Without this collection of information, determination of payment would not be possible.
The latest form for Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779) expires 2026-09-30 and can be found here.
Latest Forms, Documents, and Supporting Material
Document Name |
|---|
Form |
Supplementary Document |
Supplementary Document |
Supporting Statement A |
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)
2023-16751, 30-Day FRN (2900-0652).pdf
2900-0652, Supporting Statement (VAF 21-0779), 8-7-23.docx
Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779) All Historical Document Collections
|
Approved without change |
Revision of a currently approved collection | 2023-08-07 | |
|
Approved with change |
Extension without change of a currently approved collection | 2020-02-10 | |
|
Approved without change |
Revision of a currently approved collection | 2016-09-30 | |
|
Approved without change |
Extension without change of a currently approved collection | 2013-09-09 | |
|
Approved with change |
Extension without change of a currently approved collection | 2010-09-24 | |
|
Approved without change |
Extension without change of a currently approved collection | 2007-09-10 | |
|
Approved without change |
New collection (Request for a new OMB Control Number) | 2004-07-15 |