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 is listed under ICR 202305-2900-006.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 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 |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202305-2900-006 | Revision of a currently approved collection | 2023-08-07 | Approved without change | |
| 201911-2900-009 | Extension without change of a currently approved collection | 2020-02-10 | Approved with change | |
| 201602-2900-005 | Revision of a currently approved collection | 2016-09-30 | Approved without change | |
| 201304-2900-024 | Extension without change of a currently approved collection | 2013-09-09 | Approved without change | |
| 201006-2900-011 | Extension without change of a currently approved collection | 2010-09-24 | Approved with change | |
| 200708-2900-012 | Extension without change of a currently approved collection | 2007-09-10 | Approved without change | |
| 200407-2900-008 | New collection (Request for a new OMB Control Number) | 2004-07-15 | Approved without change |