Surviving Spouse Application

This form is for the Surviving Spouse. If you have reached the incorrect form,
please Click Here to go back and select the appropriate form.

DO NOT ATTEMPT IF YOU DO NOT HAVE EVERYTHING FROM THE CHECKLIST
ITEMS MARKED WITH AN * ARE REQUIRED For security purposes, your IP Address (18.117.101.130) is collected.
SECTION I: General Information for the Surviving Spouse Application
1.0 Your Email* THIS EMAIL ADDRESS WILL BE THE UNIQUE IDENTIFYER FOR YOUR FILE. ONLY THE EMAIL YOU HAVE ON RECORD WITH US WILL WORK -- THE EMAIL TO WHICH INSTRUCTIONS WERE SENT.
1.1 Your Name *
1.2 Your Phone Number (XXX-XXX-XXXX format)*
1.3 Surviving Spouse's Full Name*
1.4 Surviving Spouse's Date of Birth (MM/DD/YYYY format)*
1.5 Surviving Spouse's Social Security Number (XXX-XX-XXXX format)*
1.6 Veteran's First Name *
1.7 Veteran's Middle Name
1.8 Veteran's Last Name *
1.9 Enter the Veteran's Social Security Number (XXX-XX-XXXX Format)*
1.10 In Care Of Name if not being mailed to Surviving Spouse - we recommend you have it mailed to you
1.11 Street Address *
1.12 City *
1.13 State *
1.14 Zip Code*
1.15 Enter the 1st Phone Number for the VA to call - do not give the Surviving Spouse's phone number if they should not talk to the VA alone. (XXX-XXX-XXXX format) *
1.16 Enter a 2nd Phone Number (evening or cell: XXX-XXX-XXXX format)
1.17 Did the Veteran have a claim with the VA for Compensation or Pension?*
1.18 If yes, Enter the VA Claim Number (required if answer to 1.17 above is Yes)
1.19 Was the Veteran a Prisoner of War *
1.19a If yes, enter the Confinement Start Date (MM/DD/YYYY format) (required if answer to 1.19 above is Yes)
1.19b If yes, enter the Confinement End Date (MM/DD/YYYY format) (required if answer to 1.19 above is Yes)
1.20 Has the Surviving Spouse ever filed claim with the VA?*
1.21 If yes, Enter the Surviving Spouse's VA Claim Number (required if answer to 1.20 above is Yes)
1.22 Is the Surviving Spouse receiving Social Security?*
1.23 If yes, is the Social Security based on the Veteran's Work History? (required if answer to 1.22 above is Yes)
1.24 Was the Surviving Spouse ever estranged from the veteran?*
1.25 If yes, please explain the estrangement. (required if answer to 1.24 above is Yes)
SECTION II: Information from Discharge Papers
2.1 Enter the Veteran's Date of Birth (MM/DD/YYYY format)*
2.2 Did Veteran serve under a different name?*
2.3 If Yes, what was the Veteran's name while in service? ** INCLUDE name change documents in package to ERBC. (required if answer to 2.2 above is Yes)
2.4 Enter the Date the Veteran Entered their Last Period of Active Service (MM/DD/YYYY format - if unknown, enter the word Unknown)*
2.5 Enter the Place the Veteran Entered Active Service*
2.6 Enter the Veteran's Service Number*
2.7 Enter the Date the Veteran Left the Service (MM/DD/YYYY format)*
2.8 Enter the Place of Separation from the Service*
2.9 Enter the Veteran's Branch of Service *
2.10 Enter the Veteran's Rank at Discharge*
2.11 In Which Period of War did the Veteran Serve?*
2.12 Was there any additional service for the Veteran?
SECTION IV: Assisted Living or Home Care
4.1 What is the Surviving Spouse's Primary Care Medical Expense?*
4.2 Enter the Name of the Facility/Care Provider*
4.3 Enter the Amount on the Statement from the Facility/Care Provider*	$
4.4 Is the Amount Daily, Monthly or Hourly?*
4.5 If Home Care selected above, what are the hours of home care provided per month? (required if Home Care selected above in 4.1)
4.6 Enter the Street Address of the Facility/Care Provider*
4.7 Enter the City, State Zip of the Facility/Care Provider*
4.8 Please include other Assisted Living or Home Care information.
SECTION V: Medical Insurance
5.1 Enter the Medicare Deduction Amount (usually $104.90)	$
5.2 Enter the Supplemental Medical Insurance Provider
5.3 How often is the Medical Insurance Premium Paid?*
5.4 Enter the Private Medical Insurance Premium	$
5.5 Enter the Prescription/Drug Plan Provder
5.6 How Often is Prescription/Drug Plan Premium Paid?*
5.7 Enter the Prescription/Drug Plan Premium - DO NOT enter co-pays - this is for PREMIUMS ONLY	$
SECTION VI: Long Term Care (LTC) Insurance
6.0 Is the Surviving Spouse currently receiving LTC Insurance Reimbursement?*
6.1 Enter the LTC Insurance Provider
6.2 Enter the LTC Insurance Premium	$
6.3 Enter LTC Reimbursement Amount	$
6.4 When does LTC reimbursement end?
6.5 How Often is the LTC Insurance Premium paid?*
6.6 Any other LTC information?
SECTION VII: Income
7.1 Enter the Monthly Social Security Payment as deposited in the bank	$
7.2 Enter the Gross US Civil Service Amount	$
7.3 Enter the Gross US Railroad Amount	$
7.4 Enter the Gross Military Retirement Amount	$
7.5 Enter the Black Lung Benefit Amount	$
7.6 Enter the SSI (Public Assistance) Amount	$
List Each Pension Separately. If there are more than 2 pensions, list the additional pensions in the last box of this Section.
7.7 Enter the Name of Pension One
7.8 Enter the Gross Amount of Pension One Monthly Income	$
7.9 Enter the Name of Pension Two
7.10 Enter the Gross Amount of Pension Two Monthly Income	$
7.11 Enter the Gross Monthly Annuity Income Amount	$
7.12 Enter the Name of the Annuity Company
7.13 What was the Date the Annuity was purchased? (MM/DD/YYYY format)
7.14 What is the Cash Surrender Value of the Annuity - DO NOT GUESS - call and get a letter from the company, if needed.	$
7.15 Is there any other Income? Rental, Mineral rights, Additional Pensions...anything at all?
SECTION VIII: Assets and the Income they generate THESE MUST Tie to the Penny to the Statements You Provide to ERBC
If the Amount is Zero, enter 0
8.1 Enter the Amount of Money in all Non-Interest bearing accounts - look at the statement - if there is 1 penny of interest, the account belongs in the question 8.3. *	$
8.2 Enter the Amount of Money in all Interest Bearing Bank Accounts, CD's and Money Markets *	$
8.3 Enter the Sum of Interest earned in the accounts listed above - DO NOT ESTIMATE THIS MUST TIE TO statement(s) exactly - there will be an issue if off by even 1 penny *	$
8.4 Enter the Amount in all IRAs, 401k, Keough Plans, etc.	$
8.5 What is the expected IRA withdrawal for this year?	$
8.6 What is the expected IRA withdrawal for next year? NOTE large withdrawals can impact the pension -- feel free to discuss with your Servaes Consulting contact.	$
8.7 Enter the Sum of All Stocks, Bonds, Mutual Funds	$
8.8 Enter the Amount of Dividends or Interest on Stocks, Bonds or Mutual Funds	$
8.9 Enter the Value of any other assets	$
8.10 Enter the Description of other assets
8.11 If the Surviving Spouse owns a home - how much do you think it would sell for?	$
8.12 Enter the Amount of Mortgages or Liens on the Home	$
8.13 What are the plans for the home?
8.14 Are there any other assets to discuss with ERBC?
SECTION IX: Direct Deposit Information
9.1 Enter the Name of the Surviving Spouse's Bank*
9.2 Enter the Routing Number of the Surviving Spouse's Bank (9 digit number - if there are leading zeros, include them) *
9.3 Enter the Surviving Spouse's Bank Account Number *
SECTION X: Information from Death Certificate
10.0 What was the Date of the Veteran's Death? (MM/DD/YYYY format)*
10.1 Enter the City and State of the Veteran's Death?*
10.3 Is the Cause of Death listed on the Death Certificate?*
SECTION XI: Veteran and Spouse Marriage Information
11.1 How many times was the Veteran married?*
11.2 How many times was the Surviving Spouse married?*
11.3 What was the date the Veteran and Surviving Spouse married? (MM/DD/YYYY format)*
11.4 In what City and State were the Veteran and Surviving Spouse married?*
11.5 How did the marriage between the Veteran and Surviving Spouse end?*
SECTION XII: Veteran's Prior Marriage(s)
12.1 To whom was the Veteran previously married?
12.2 What was the date the prior marriage occured? (MM/DD/YYYY format or Unknown)
12.3 In what City and State was the Veteran's prior marriage?
12.4 How did the Veteran's prior marriage end?
12.5 What was the date the prior marriage ended? (MM/DD/YYYY format or Unknown)
12.6 In what City and State did the Veteran's prior marriage end?
12.7 Did Veteran have additional prior marriages? Put information here and don't forget to send us Death or divorce decree.
SECTION XIII: Surviving Spouse's Prior Marriage(s)
13.1 To whom was the Surviving Spouse previously married?
13.2 What was the date the prior marriage occured? (Enter a date if known in MM/DD/YYYY format, or enter Unknown if the date is not known)
13.3 In what City and State was the Surviving Spouse's prior marriage?
13.4 How did the Surviving Spouse's prior marriage end?
13.5 What was the date the prior marriage ended? (MM/DD/YYYY format)
13.6 In what City and State did the Surviving Spouse's prior marriage end?
13.7 Did Surviving Spouse have additional prior marriages? Put information here and don't forget to send us Death or divorce decree.
SECTION XIV: Other Information
14.1 Is there anything else you think ERBC should know?
You will have the opportunity to review your answers on the next page before final submission.

Surviving Spouse Application

This form is for the Surviving Spouse. If you have reached the incorrect form,please Click Here to go back and select the appropriate form.

This form is for the Surviving Spouse. If you have reached the incorrect form,
please Click Here to go back and select the appropriate form.