Intake Form

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Please correct the fields below:

Please correct the field(s) marked in red below:

In order to best serve you, we ask that you answer all questions completely and to the best of your knowledge. A representative will respond within 3 business days. Thank you.

Veteran

*

First Name

Middle Name

Last Name

Date of birth

Place of birth (city, state)

Last four of SSN

Is the veteran deceased?

*

Is the veteran deceased?

Yes

No

Date of death

Place of death (city, state)

Contact Info (Veteran or next-of-kin)

*

Contact Info (Veteran or next-of-kin)

Address

City

State

Zip Code

Home Phoneext.

Cell Phoneext.

Email

NOK Name

NOK Relationship

Preferred method of contact. (Email is generally the quickest way to get a response.)

*

Preferred method of contact. (Email is generally the quickest way to get a response.)

Email

Phone

No preference

Cass County, ND

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Intake Form