Veteran'S Interview Form - Client Information Page 3
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3Are you age 65 or older? Yes: ____ No: ____
Are you currently employed? Yes: ____ No: ____
If yes, where: _________________________________________________________________
If not, what is the reason for your unemployment: ___________________________________
____________________________________________________________________________
____________________________________________________________________________
Do you have any income other than employment? Yes: ____ No: ____
If yes, please provide the amount and source of your income: __________________________
____________________________________________________________________________
____________________________________________________________________________
Thank you for your time and service to our country. We look forward to assisting you during
this process!
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M:\VA\Veterans Interview Form.docx
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