Find Out If You Qualify for Medicaid or VA Aid & Attendance Questionnaire Your Name * First Name Last Name Your Email * Your Phone * (###) ### #### The Medicaid or VA Applicant Name(s) * Applicant County of Residence * Moving to Colorado Not Listed Adams County Alamosa County Arapahoe County Archuleta County Baca County Bent County Boulder County City & County of Broomfield Chaffee County Cheyenne County Clear Creek County Conejos County Costilla County Crowley County Custer County Delta County Denver County Dolores County Douglas County Eagle County Elbert County El Paso County Fremont County Garfield County Gilpin County Grand County Gunnison County Hinsdale County Huerfano County Jackson County Jefferson County Kiowa County Kit Carson County La Plata County Lake County Larimer County Las Animas County Lincoln County Logan County Mesa County Mineral County Moffat County Montezuma County Montrose County Morgan County Otero County Ouray County Park County Phillips County Pitkin County Prowers County Pueblo County Rio Blanco County Rio Grande County Routt County Saguache County San Juan County San Miguel County Sedgwick County Summit County Teller County Washington County Weld County Yuma County Your Relation to the Applicant * Myself Family Member Friend Other Applicant Age * Over 65 Under 65 Applicant Marital Status * Single Divorced Widowed Married Applicant Income * Under $8,000 Over $8,000 If applicable, Applicant Spouse's Income * Under $8,000 Over $8,000 NA SUM of Checking / Savings: * Under $2,000 Over $2,000 SUM of Investment / Retirement Accounts * IRAs, CDs, Stock, Bonds Under $2,000 Over $2,000 Does the Applicant have Life Insurance / Burial Policies? * Yes No Does the Applicant have a House? * Yes No Does the Applicant own more than 1 home or property? * Yes No Does the Applicant own a registered Vehicle? * Including Car(s), Boat(s), Trailer(s), Tractor(s), Motorcycle(s) Yes No The Applicant does need assistance with activities of daily living * Activities of Daily Living Examples: Cooking, Bathing, Toileting, Dressing Yes No Does the Applicant have a Trust? Yes No If a Veteran, the Vet served 90 days of active duty, with at least one day during wartime * Yes No NA I want to be contacted about my results Yes No Thank you for submitting our questionnaire. A Beneficent Staff Member is personally reviewing your answers and will contact you within 2 business days.