Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779)

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.

The latest form for Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779) expires 2023-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form VA Form 21-0779 Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779) Form
2023-16751, 30-Day FRN (2900-0652).pdf Supplementary Document
2023-11409, 60-Day FRN (2900-0652).pdf Supplementary Document
2900-0652, Supporting Statement (VAF 21-0779), 8-7-23.docx Supporting Statement A
Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779) Form

202305-2900-006 Approved without change	Revision of a currently approved collection	2023-08-07
201911-2900-009 Approved with change	Extension without change of a currently approved collection	2020-02-10
201602-2900-005 Approved without change	Revision of a currently approved collection	2016-09-30
201304-2900-024 Approved without change	Extension without change of a currently approved collection	2013-09-09
201006-2900-011 Approved with change	Extension without change of a currently approved collection	2010-09-24
200708-2900-012 Approved without change	Extension without change of a currently approved collection	2007-09-10
200407-2900-008 Approved without change	New collection (Request for a new OMB Control Number)	2004-07-15