Request for Provision of Attendant Care Services by a Partner, Relative or Friend

This form is to confirm that exceptional circumstances exist requiring a partner, relative or friend to provide Attendant Care Services to an approved client with the Department of Veterans’ Affairs (DVA). This form is only to be completed following a request from the client to DVA to consider exceptional circumstances.

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.