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APPLICATION FOR ADMISSION TO STATE VETERANS HOME
ODVA Form #401 | Revised 11/2016 | Oklahoma Department of Veterans Affairs
VETERAN'S INFORMATION
(City & State)

Marriage 1

ex. ceremony, common, tribal
ex. death, divorce

Marriage 2

ex. ceremony, common, tribal
ex. death, divorce

Marriage 3

ex. ceremony, common, tribal
ex. death, divorce

EDUCATION

MILITARY SERVICE INFORMATION
Select ONE

First Stint of Active Duty

Select ONE

Second Stint of Active Duty

Select ONE

(If veteran served more than two active-duty stints in military service, attach an additional sheet with the same information as above for each additional stint.)


AS PROOF OF THE VETERAN'S MILITARY INFORMATION PROVIDED, THE FOLLOWING IS REQUIRED:

  1. VETERAN'S DISCHARGE PAPERS (FORM DD-214) OR OTHER SEPARATION DOCUMENTS FOR EACH STINT OF SERVICE.
  2. VERIFICATION OF POW STATUS (IF CHECKED "YES" FOR EX-POW).
  3. VA DISABILITY RATING DOCUMENT (IF CHECKED "YES" FOR SERVICE CONNECTED DISABILITY RATING FROM VA).

FAMILY INFORMATION
Note: Birth date and Social Security number is required for Spouse and all dependent children of the Veteran

Primary Contact


Other Contact


Other Contact


Other Contact


Required
LEGAL INFORMATION
(Check all applicable and attach copies of the documents.)
(If yes, attach copies of applicable documents.)
(If yes, attach copies of applicable documents.)
(If yes, attach copies of applicable documents.)
(If yes, attach copies of applicable documents.)

REQUIRED DOCUMENTS:

COPY OF THE LEGAL DOCUMENT FOR ANY OF THE ABOVE IDENTIFIED AS THE LEGAL GUARDIAN.
IF VETERAN REGULARLY CONTRIBUTES TO SUPPORT OF A SPOUSE, PROVIDE COPY OF THE MARRIAGE CERTIFICATE.
IF VETERAN CONTRIBUTES REGULARLY TO SUPPORT OF A DEPENDENT CHILD, PROVIDE COPY OF BIRTH CERTIFICATE FOR EACH.


MEDICAL INFORMATION

FOR ADMISSION TO AN OKLAHOMA VETERANS CENTER, A CURRENT PHYSICIAN'S STATEMENT OR HOSPITAL SUMMARY CONTAINING DIAGNOSIS, PROGNOSIS, MEDICATIONS AND HISTORY IS REQUIRED.

Veteran's Physician

IF WITHIN THE LAST YEAR, THE VETERAN HAS BEEN IN A HOSPITAL, NURSING HOME OR OTHER FULL OR PARTIAL CARE FACILITY, PLEASE PROVIDE THE FOLLOWING INFORMATION FOR THE FACILITIES.