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CaseSix Benefits Evaluation & Intake Q&A

Veteran's Name *

First

Middle

Last

(Middle Name or Initial)

Nick Name

Housing Status *

Has accommodations
Homeless
Incarcerated
Unspecified

Primary Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

What COUNTY (not Country) is your address in? *

The VA is now asking for the county you live in.

Mobile Phone # *

Preferred Email *

Preferred contact method(s) *

Phone
Text
Email

Check all that apply.

What is your Time Zone? (we're Eastern) *

'Other' Timezone

Please enter the Time Zone you live in. If you're not sure, this Time Zone website is helpful: https://www.timeanddate.com/worldclock/

Mother's Maiden Last Name *

We use your Mother's Maiden Last Name to create your Unique Password.

Date of Birth *

Place of Birth *

City, State (Country if other than USA)

Marital Status *

Married
Single
Divorced
Widowed

Employment Status *

Employed
Self Employed (LLC, Inc. or Org.)
Unemployed
Unspecified

Name of Business (LLC, Inc, Org) (optional)

Some Veterans who are self-employed or work as independent contractors prefer to manage transactions and communications through their business entities. This approach can offer key advantages, such as: – Claiming business-related expenses – Qualifying as a Service-Disabled Veteran-Owned Small Business (SDVOSB) for federal or state contracting opportunities if they have a VA service-connected disability (Ask us how!)

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Social Security Number Security Layer

We need your Social Security Number (SS#) to complete VA Form 21-22a and access your VA records. To help protect your privacy, we divide the SS# into three separate fields.

If you wish for added security, enter “XXX”, “XX” and provide only the last four digits of your SS#; we that, in part to create your unique ID and password. You can provide the first five digits by phone later.

First Three (3) Digits (or enter "XXX") *

Middle Two (2) Digits (or enter "XX") *

Last Four (4): *

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Technology Comfort Check

This part allows us to gauge your ease with technology, ensuring we communicate and gather required files and signatures effectively. Your responses will help tailor our approach to suit your comfort level.

How comfortable are you with using QR Codes? *

Very
Somewhat
Not at All

Click on the QR Code to select

How comfortable are you with using Video Conferencing platforms to communicate? *

Very
Somewhat
Not at All

Like Zoom, Google Meet, WebEx and the like.

How comfortable are you with using eSignature solutions for signing documents electronically? *

Very
Somewhat
Not at All

Like DocuSign, Dropbox Sign, VineSign, etc.

How comfortable are you with using File Sharing for Uploading/Downloading files? *

Very
Somewhat
Not at All

File Sharing platforms include Dropbox, Filevine, iCloud, Google Drive, OneDrive, and the like.

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Military History

Do you have your DD214? *

Branch of Service. Select up to three (3) *

Army
Navy
Air Force
Marines
Coast Guard
Space Force
Army National Guard/Reserve
Air National Guard/Reserve
Coast Guard Reserve
Marine Corps Reserve
Navy Reserve

What is your current military status? *

Military Discharge/Character of Service *

Honorable
General
Under Hororable Conditions
Other Than Honorable (OTH)
Entry-Level Separation
Medical Separation
Separation for Convenience
Bad Conduct
Dishonorable

What is/was your Rank? *

i.e. PFC, PO3, SSgt, CPO, SgtMajMC

What is/was your MOS (AlphaNumeric/Job Description)? *

i.e. 13F - Joint Fire Support Specialist

Military Start Date *

If you are not sure of the exact date, please provide your Month and Year and use '01' as your day.

Military End Date (or Project Date) *

If you are not sure of the exact date, please provide your Month and Year and use '01' as your day.

Place of Entry *

City, State, Country

Place of Separation *

City, State, Country

Were you in combat? *

Combat Theater(s) (Check all that apply) *

Peacetime
WWII
Korean War
Vietnam War
Desert Storm/Gulf War I
Operation Enduring Freedom / Iraqi Freedom (OEF/OIF)
Operation New Dawn (OND)

Significant Awards: Do you have any of the following? *

None
Congressional Medal of Honor
Distinguished Service Cross
Distinguished Flying Cross
Air Force Cross
Navy Cross
Silver Star
Bronze Star
Purple Heart
Combat Action Badge/Ribbon
Combat Infantryman Badge/Ribbon
Combat Medical Badge/Ribbon
Armed Forces Expeditionary Medal (AFEM)

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VA Benefits History

Have you ever filed or tried to file a claim with the VA? *

What type of claim would you like file with the VA? *

1. I'm not sure
2. Original: I have never filed.
3. New Claim: I have a new condition to claim.
4. Increase: My condition has worsened
5. Reopen: VA denied my claim.
6. Appeal: I disagree with the VA's decision.
7. CUE: I think the VA made an error rating my claim.

Check all that apply.

Did you receive a lump sum payment (separation pay) when you separated from the military? *

Yes; there is a balance
Yes; there is NO balance
No
Not Sure

VA Recoupment of Separation Pay: The VA deducts the taxable portion of separation pay from disability compensation until the full amount is repaid, ensuring veterans don't receive both benefits for the same service period or claimed condition. Rules vary based on when the separation pay was received. Ask CaseSix for more information.

Are you currently working with another Attorney/Claim Agent (POA) or VSO? *

Do you currently have a claim PENDING with the VA? *

Date Your VA Form 21-0966 (Intent to File) Was Filed with VA?

VA Form 21-0966 begins your filing process and allows up to 1 Year to gathering information and evidence in support of your claim. Submitting the Intent To File (ITF) secures the earliest possible effective date for any retroactive payments you may be eligible for.

Are you receiving Disability compensation from VA? *

Yes
No
No VA Rating

If any, what are your Service-Connected condition(s)?

What is your Combined VA Rating Percentage (%)? *

Did you know many U.S. states offer "Disabled Veteran" license plates to honor veterans with service-connected disabilities. While some states require a 100% VA disability rating, others, like Maryland, allow eligibility with a rating of 50% or higher. Benefits and requirements vary by state. To learn more, visit your state’s Department of Motor Vehicles (DMV) website or contact the VA for assistance with eligibility documentation.

Vets with a Rating of 30% or Higher are Entitled to Increased Benefits. *

This refers to VA Form 21-686c (Add/Remove Dependents). Vets with a Rating of 30% or higher are entitled to increased benefits if they have • a Spouse • Child(ren) under age 18 • Between the ages of 18 & 23 who are attending school • Over 18 who are permanently incapable of self-support &/Or • Dependent parent(s).

Subsequent VA Forms are 21-674: Request for School Attendance &/Or 21-509: Statement of Dependent Parent(s)

Check All That Apply. (Refers to VA Form 686c)

Spouse
Previous Marriage
Dependent Child(ren)
Dependent Parent(s)

Do You Have Children Under the Age of 23? *

Vets with a Rating of 30% or higher are entitled to increased benefits if they have • a Spouse • Child(ren) under age 18 • Between the ages of 18 & 23 who are attending school • Over 18 who are permanently incapable of self-support.

Subsequent VA Forms are 21-674: Request for School Attendance

Do you have any VA DENIED condition(s)? *

What are your DENIED condition(s)?

What conditions do you want to file with the VA?

Do you have copy(ies) of VA Rating Decision letter(s)? *

Do you have your Military Medical Records/Service Treatment Records (STR)? *

Where Do You Receive Your Regular Healthcare? *

VA Med. Center (VAMC)
Private/Family Doctor
Both VAMC & Private/Family Dr.

Do you have Private Treatment (TX) or Diagnosis (DX) Records? *

Private Treatment (TX) or Diagnosis (DX) Records are from your Family Doctor, Specialist or VA Medical Center.

Tell Us More... (if you’d like)

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Let's Wrap It Up.

Quick Survey: How did you hear about us? (Check all that apply) *

Internet Search
VA Website
Vehicle Signage
YouTube Video
Facebook/Instagram
Nextdoor
LinkedIn
"X" (Twitter)
SiriusXM
Personal Meeting (Where?)
Referral (Who?)

Referral's Name / Personal Meeting Place

What Size T-Shirt Do You Wear?

Think standard men's size.

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We very much appreciate you completing our Q&A. This information is beneficial in our conversation and evaluating your case.

Intake & Eligibility Review Q&A