Form VA Form 21-526 and VA Form 21-526 and Veteran's Application for Compensation;Authorization and

Veteran's Application for Compenstion;Authorization and Consent to Release Information to the Department of Veterans Affairs

2900-0001 VA Form 21-526 and 21-4142

Veteran's Application for Compenstion; Authorization and Consent to Release Information to the Department of Veterans Affairs

OMB: 2900-0001

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2900-0001 can be found here:

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GENERAL INSTRUCTIONS
FOR VETERAN’S APPLICATION FOR COMPENSATION
VA FORM 21-526
NOTE: Read very carefully, detach, and keep these instructions for your reference.

A. How can I contact VA if I have questions?
If you have questions about VA benefits, this form or how to fill it out, contact your nearest VA regional office. You
can locate the address of the nearest regional office in your telephone book blue pages under "United States
Government Veterans" or call 1-800-827-1000 (Hearing Impaired TDD line 1-800-829-4833). You may also contact
VA by Internet at http:// www.vba.va.gov/benefits/address.htm.
B. How can I get information about Social Security Benefits?
Individuals with a disability who meet certain medical criteria may qualify for benefits under the Social Security or
Supplemental Security Income disability programs. These programs are administered by the Social Security
Administration (SSA). For more information, contact SSA. You can locate the address of the nearest SSA office in the
blue pages of your telephone book under "United States Government, Social Security Administration" or call
1-800-772-1213 (Hearing Impaired TTY line 1-800-325-0778). You can also contact SSA by Internet at www.ssa.gov.
C. What is the purpose of VA Form 21-526?
Use VA Form 21-526 to apply for compensation for service-connected disabilities.
D. What is disability compensation and how does VA decide what I will or will not receive?
VA pays veterans disability compensation for disability(ies) that are a result of their military service. If VA determines
that your disability(ies) are 30% or more disabling, VA can pay additional compensation for your spouse, children, and
dependent parents. VA will pay a higher amount of compensation for a spouse when the spouse is a patient in a nursing
home or is disabled and requires regular aid and attendance of another person.
If any of the following are true, use VA Form 21-526 to apply for compensation:

. You were injured or seriously ill during service
. You believe you have continuing problems as a result of a service-related condition
. You developed a mental or physical disorder that may be related to your service

E. What evidence should I submit?
If you have records that support your claim you should attach them to this application. Refer to the checklist on page 2
of these instructions for a list of records you should submit. If you know of other records that will support your claim,
VA will help you by requesting them from the person, company, or agency that has them.
If you want help obtaining existing non-VA medical records, you must complete the attached VA Form 21-4142,
Authorization and Consent to Release Information to the Department of Veterans Affairs (VA). By signing VA Form
21-4142, you authorize any doctors, hospitals or caregivers that have treated you to release information about your
treatment to VA. You do not need to complete this form for any treatment you received at a VA facility. Complete a
separate VA Form 21-4142 for each medical provider. If you need additional copies of this form, you may contact VA
as shown in paragraph A, download the form from our website at http://www.va.gov/vaforms/ , or photocopy the
attached form.
Note : You may complete and submit this application electronically at http://vabenefits.vba.va.gov/vonapp/main.asp.

VA FORM
NOV 2006

21-526

SUPERSEDES VA FORM 21-526, JAN 2004, WHICH
WILL NOT BE USED.
General Instructions Page 1

F. How do I complete my application?
You will find instructions for completing each section of VA Form 21-526 in the checklist below. Your answer to
every question is important in assisting us to decide your claim. Print all answers clearly. If an answer is "none" or "0,"
write that. If you do not know the answer, write "unknown." For additional space, use Item 52 "remarks" or attach a
separate sheet of paper to your form, identifying the item number to which your answer applies.
CHECKLIST: THINGS YOU’LL NEED TO PREPARE FOR FILLING OUT YOUR APPLICATION
When you fill out this
VA Form. . .

You’ll need this information ready to answer
questions. . .
Dates and places you entered and left
active duty

Sections II
through
IV

Date and place your Reserve and/or National
Guard service began and ended
(If applicable)
Mailing addresses of the Reserve or National
Guard units in which you served

Section V

Date(s) and place(s) of your injury while on travel

Section VI

Type and amount of military benefits you receive
Information about the disabilities you are
claiming, including

.
.

Section VII

treatment dates during service
name and address of the medical
facilities where you have been
treated since service ended

Information about any exposure to toxins or
events that caused disabilities you are
claiming, including dates and places where
the exposure(s) occurred

Information about your current spouse,
including:
social security number

Section VIII and IX

.
.
.

date of birth

You should attach these
documents. . .
Original or certified copies of your
DD214 or other separation
documents for all periods of service
Note: To obtain a certified copy, you can
take the original to your local courthouse
and have it copied and signed by an
official of the court. A VA employee can
also certify a copy of the original for you

Original or copies of service medical
records in your possession
Medical records you possess
showing your disabilities still exist
Medical records you possess
indicating that the disabilities were
caused by or happened during active
duty
Completed VA Form 21-4142 for
each non-VA medical care provider
whose records you would like us to
help you obtain
A copy of your marriage certificate
and all divorce decrees may be
required upon request by VA

VA file number if he/she is
a veteran

Information about you and your spouse’s
previous marriages, including:
dates and places of those marriages

.
.
.
.

dates and places those marriages

Information about your children, including:

Section X

social security number
dates and places of birth

Additional information about your children
who are not living with you, including:

.
.

Copies of the public birth records for
each child you claim as a dependent
may be required in some cases

addresses

Copies of the court records of
adoption for each adopted child

amounts that you contribute in
child support for them

Section X

Direct Deposit Information

Voided Check

Section XII

Sign and date your application

If you sign with an "X," two persons
must witness it, and you must provide
their names and addresses

Section XIII

Any additional information you would like to provide
VA as it relates to your claim
General Instructions Page 2

G. What do I do when I have completed my application?
1. Make sure you sign and date this application (Items 48 and 49)
2. Attach any materials that support and explain your claim. Review the checklist on pages 2 and 3 of these
instructions to make sure you have attached all supporting material.
3. Make a photocopy of your application and everything that you submit to VA for your records.
4. Mail or take your original application and supporting materials to your nearest VA regional office.
Note : If you find you need to change or add information to your application, contact the VA office where you
submitted your application immediately.
H. How can I assign someone to act as my representative?
A representative may be an accredited member of an accredited organization that the Secretary of Veterans Affairs
recognizes, an agent recognized by VA, or a licensed lawyer. Agents and attorneys may charge you for service they
provide only after the Board of Veterans’ Appeals (BVA) gives you its final decision about your claim. That means
you can use an attorney during any stage of your application for benefits. However, the agent or attorney is prohibited
by law from charging you for services unless you are trying to resolve a dispute with VA after BVA has made a
decision about your claim.
If you want to use a representative to help you with your application, contact the nearest VA regional office.
Depending on the type of representative you want to designate, we will send you one of the following forms:
VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative, or
VA Form 21-22a, Appointment of Individual as Claimants Representative.
You may also download these forms at http://www.va.gov/vaforms/.
representative, no further action is required on your part.

If you have already designated a

I. What if I believe VA made an error in processing or deciding my claim?
You may ask for a personal hearing at any time. That means you may ask for the hearing while VA is processing your
claim or after VA has made a decision. You should contact the nearest VA regional office and tell them that you want
a personal hearing on your case. Someone in that office will arrange a time and a place for your hearing. At this
hearing, you may bring witnesses. VA will record whatever you and your witness say during the hearing and include
it in the official record. VA will furnish the hearing room and official, and prepare a transcript of the hearing. VA
cannot pay your expenses or the expenses of anyone you want to bring with you to the hearing.

Privacy Act Notice: The VA will not disclose information collected on this form to any source other than what has been authorized
under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law
enforcement, congressional communications, epidemiological or research studies, the collection of money owed the United States,
litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits,
verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22,
Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation to respond
is voluntary; however, no allowance of compensation may be granted unless this form is completed fully as required by law. Giving
us your and your dependents’ Social Security number is mandatory. Applicants are required to provide their SSN and the SSN of
any dependents for whom benefits are claimed under Title 38 USC 5101 (c) (1). The VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January
1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under
the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification
through computer matching programs with other agencies. Income and employment information furnished by you will be compared
with information obtained by VA from the Secretary of Health and Human Services or the Secretary of the Treasury under clause
(viii) of section 6103 (1)(7)(D) of the Internal Revenue Code of 1986.
Respondent Burden: We need this information to determine eligibility for compensation (38 U.S.C. 5101). Title 38, United States
Code, allows us to as for this information. We estimate that you will need an average of 1 hour and 30 minutes to review the
instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid
OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed.
Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.html#VA. If
General Instructions Page 3

OMB Approved No. 2900-0001
Respondent Burden: 1 hour 30 minutes

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

VETERAN’S APPLICATION FOR COMPENSATION
VA Form 21-526
Please read the attached "General Instructions"before you fill out this form.

SECTION
I

Tell us
about
you

1. What is your name?
First

Middle

Last

2. What is your social security number?

Suffix (If applicable)

3. What is your sex?
Female

Male

4a. Have you ever filed a claim with VA?

4b. I filed a claim with VA for
Compensation

(If "Yes," provide file number below
and complete Item 4b)

Yes

Pension
Other

(VA File Number)

(If "No," go to Item 5)

5a. Did you serve under another name?
Yes Yes (If "Yes," go to Item 5b)
Give us your current
mailing address in the
space provided. If it
will change within the
next three months,
give us that new
address in Item 52,
"Remarks." Also in
Item 52, give us the
date you think you will
be at the new
address.

No Yes (If "No," go to Item 6)
6. What is your address?
Street address, rural route, or P.O. Box

City

Apt. number

State

7. What are your telephone numbers?
(
)
Daytime
Evening

(

day

year

11a. Are you receiving disability
benefits from the Office of Workers’
Compensation (OWCP)?
Yes

12c. What is this person’s address?

21-526

Country

8. What is your e-mail address?

10. Where were you born?
City

State

Country

11b. When was the claim filed?
month
year
11c. For what disability are you receiving
benefits?

( If "Yes," answer 11b and 11c also)

12a. What is the name of your nearest
relative or other person we could
contact if necessary?

VA FORM
NOV 2006

ZIP Code

)

9. What is your date of birth?
month

OWCP used to be
called the U.S. Bureau
of Employees
Compensation

5b. Please list the other name(s) you served
under

12b. What is his/her telephone number?
Daytime

(

)

Evening

(

)

12d. How is this person related to you?

SUPERSEDES STOCKS OF VA FORM 21-526, JAN 2004,
WHICH WILL NOT BE USED.

21-526

Page 1

SECTION
II

Tell us
about
your
active
duty

1. Enter complete
information for all
periods of service.
If more space is
needed, use Item 52
"Remarks".
2. Attach your original
DD214 (discharge
papers) or a certified
copy to this form
(We will return original
documents toyou.)
The VA has a registry of
veterans who served in
the Gulf War theater of
operations. If you served
there, we will include
your name in the registry.
If you want your medical
information included, you
must check "Yes" in Item
15b. VA will only share
the information in this
registry with the
Department of Defense
and others as permitted
by law (such as the
National Academy of
Sciences). We will keep
you informed of
significant developments
in research on health
consequences found to
be related to military
service in the Gulf War.
You may request a VA
health examination that
will include consultation
and counseling covering
the results of the
examination. You should
contact our nearest VA
medical facility to request
an examination.

SECTION
III

Tell us
about
your
reserve
duty

13b. Place:
13a. I entered active
service the first time. . .
mo

day

13d. I left this active
service. . .
mo

day

13f. Branch of
Service

13g. Grade, rank,
or rating

13i. Place:

13j. My service
number was . . .

13l. Place:

13m. Branch of
Service

13k. I left this active
service. . .
mo

13e. Place:

13h. I entered
my second period of
active service. . .
mo

13c. My service
number was . . .

13n. Grade, rank,
or rating

14a. Did you serve in Vietnam?
Yes

14b. When were you in Vietnam?
from

(If "Yes," answer Item 15b also)

15a. Were you stationed in the Gulf after
August 1, 1990?

to
day

day

15b. Do you want to have medical and other
information about you included in the
"Gulf War Veterans’ Health Registry?"

Yes

(If "Yes," answer Item 15b also)

16a. Have you ever been a prisoner
of war?
No
Yes

16b. What country or government
imprisoned you?

(If "Yes," answer Items 16b, 16c, and 16d also)

16c. When were you confined?
from

16d. What was the name of the camp or
sector, and what are the names of the city
and country near its location?

day

17a. Are you currently assigned to
an active reserve unit?
Yes

17b. What is the name, mailing address, and
telephone number of your current unit?

(If "Yes," answer Item 17b also)

17c. Were you previously assigned to an
active reserve unit within the last 2
years?
Yes

17d. What is the name, mailing address, and
telephone number of that unit?

(If "Yes," answer Item 17d also)

21-526

Page 2

(Continued)

SECTION Tell us
III
about

your
reserve
duty
Instructions 17g-17k
If you are currently or have
ever been a full time
reservist for operational or
support duty,
1. Complete 17g-17k for
that service only.

17e. Do you have an inactive reserve
obligation? (You perform no active
duty, but you could be activated if
there was a national emergency)
Yes

17g. I entered reserve service. . .

1. Complete 17l-17p for
the period when your
disability occurred.

day

17i. I left reserve service. . .

National
Guard
duty

17h. My service number was . . .

17j. Branch of
service

17k. Grade, rank,
or rating

Place:
day

17l. I entered reserve service. . .

17m. My service number was . . .

Place:
mo

day

17n. I left reserve service. . .

17o. Branch of
service

17p. Grade, rank,
or rating

Place:
mo

Tell us

2. Attach proof that your
disability occurred
during reserve service.

SECTION about
IV
your

day

Place:
mo

If your disability occurred or
was aggravated during any
period of reserve duty,

(If "Yes," answer Item 17f also)

2. Attach proof of reserve
service

Instructions 17l-17p

Don’t know

17f. What is your reserve obligation
termination date?

day

18a. Are you currently a member of
the National Guard?
Yes

18b. What is the name, mailing address, and
telephone number of your current unit?

Not assigned yet

(If "Yes," answer Item 18b also)

18c. Were you previously assigned to a
guard unit within the last 2 years?
Yes

18d. What is the name, mailing address, and
telephone number of that unit?

(If "Yes," answer Item 18d also)

Instructions 18e-18i
If you were activated to
Federal active duty under
the Authority of Title 10,
United States Code,
1. Complete 18e-18i for
that service only

18e. I entered Federal Active Duty. . .
Place:
mo

day

18g. I left Federal Active Duty. . .

2. Attach proof of this
Federal Active Duty.

If your disability occurred or
was aggravated during any
period of Guard duty,
1. Complete 18j-18n
for the period when
your disability occurred
2. Attach proof that your
disability occurred
during National Guard
service.

18h. Branch of
service

18i. Grade, rank,
or rating

Place:
mo

Instructions 18j-18n

18f. My service number was . . .

day

18j. I entered the National Guard. . .

18k. My service number was . . .

Place:
mo

day

18l. I left National Guard. . .

18m. Branch of
service

18n. Grade, rank,
or rating

Place:
mo

day

yr
21-526

Page 3

Tell us
SECTION about
your
V
travel
status

19a. Were you injured while
traveling to or from your
military assignment?
Yes

19b. When did your
injury happen?

day

19c. Where did your injury
happen? (City,State,Country)

(If "Yes," answer Items 19b thru 19e)

19d. Where were you treated? (Provide name and
address of Doctor’s office, hospital, etc.)

Tell us

SECTION about
VI
your

19e. With what agency did you
file an accident report?

20a. Are you receiving or will you receive retired pay or retainer pay that
is based on your military service?

military
benefits

Yes

(If "Yes," answer Items 20b thru 20d)

(If "No," skip to Item 21)

Note: If you are receiving or
are entitled to receive
20b. What branch of service is paying or will pay your retired pay?
military retired pay, your
military retired pay may be
reduced by the amount of
any compensation that VA
may award you. However,
20c. What is the monthly amount?
this is to your advantage,
because VA compensation
is not taxable and most
$
.
retired pay is taxable. Your
signature on this application
Monthly Amount
indicates to us, without
separate notice, that you
want to get VA
20d. What is your retirement based on?
compensation instead of
military retired pay. Military
Length of service
retired pay in excess of VA
compensation will still be
awarded to you if VA
Disability
compensation is granted. In
some cases you may be
entitled to both VA
TDRL (Temporary Disability Retired List)
compensation and military
retired pay or Combat
Related Special
20e. Have you received or will you receive any of the following military benefits?
Compensation. VA notifies
(Please check the appropriate boxes and tell us the amount)
the Military Retired Pay
Center of awards of VA
benefits and all VA benefit
Amount
Benefit
changes. The Department
of Defense determines if
you are eligible for
(1)
Lump Sum Readjustment Pay
$
payments from your service
branch.
(2)
If you received any of these
military benefits
(3)
and VA benefits are
awarded, the amount you
received may be recouped
by VA, or in
(4)
the case of VSI, by the
Department of Defense.
(5)

(6)

Separation pay under 10 USC 1174

21-526

Page 4

Special Separation Benefit (SSB)

Voluntary Separation Incentive (VSI)

Disability Severance Pay (name of disability____________________)

Other (tell us the type of benefit______________________________)

SECTION Tell us
about
VII

your
disability

.
..

In the table below, tell us more about your disability or disabilities. Be sure to:
List all disabilities you believe are related to military service. Try to list the
actual disease and medical condition that a doctor has diagnosed.
List all the treatments you received for your disabilities, including
treatments you received in a military facility before and after
discharge.
treatments you received from civilian and VA physicians before, during, and
after your service.

21a. What disability are
you claiming?

21b. When
did your
disability
begin?

21c. When were you
treated?

from
mo day yr

mo day yr

from
mo day yr

mo day yr

from
mo day yr

mo day yr

from
mo day yr

mo day yr

from
mo day yr

mo day yr

from
mo day yr

mo day yr

from
mo day yr

mo day yr

from
mo day yr

mo day yr

21d. What medical
facility or doctor
treated you?

21e. What is the address
of that medical
facility or doctor?

to
mo day yr

from

mo day yr

mo day yr
21-526

Page 5

Tell us

SECTION about
VII
your

22a. Did you have a separation or
retirement physical examination?
Yes

disability
(Continued)

22b. When was the
exam?

22c. Where did the
exam occur?

(If "Yes," answer Items 22b and 22c also)

day

23. Do you have a medical condition (pregnancy, recent surgery, allergy to contrast
media, etc.) that may prevent you from undergoing a VA physical examination?

24a.

Yes
No
Did exposure to Agent Orange
or other herbicides cause your
disability?
No
Yes

24b. What is your disability?

24c. In what
country were
you exposed?

(If "Yes," answer Item 24b and 24c also)

25a. Did exposure to Asbestos cause
your disability?
Yes

25b. What is the disability?

25c. When and how were you exposed?

(If "Yes," answer Items 25b and 25c also)

26a. Did exposure to mustard gas
cause your disability?
Yes

26b. What is the disability?

26c. When and how were you exposed?

(If "Yes," answer Items 26b and 26c also)

27a. Did exposure to ionizing radiation
cause your disability?
Yes

(If "Yes," answer Items 27b through 27d)

27b. What is the disability?

27c. What are the dates and places of
exposure, OR what is the operation or
test-shot code name?

27d. How were you exposed to radiation?
Atmospheric or oceanic testing
American occupation of Nagasaki or Hiroshima
Military duties (occupational exposure) (Describe circumstances below in Item 29)

28a. Did exposure to an environmental
hazard in the Gulf War cause your
disability?

28b. What is the disability?

28c. What was the hazard?
Yes

(If "Yes," answer Items 28b through 28c)

29. How are the disabilities listed in Item 21a related to your military service?

21-526

Page 6

Tell us
SECTION about
your
VIII
marriage

30. What is your marital status?
Married
Surviving spouse

Divorced

Never married

(If your spouse died, you are "divorced," or "never married" skip to Section X)

31. When were you married?

32. Where did you get married?

NOTE: You
should provide
mo

a copy of your
marriage
certificate.

day

(city/state or country)

33. How were you married?
a.

Ceremony by a clergyman or
other authorized public official

Common law

Tribal

Proxy

Other (please describe in the space below)

34. What is your spouse’s name?

35. When is your spouse’s birthday?
mo

day

36. What is your spouse’s social security
number?

37a. Is your spouse also a veteran?

37b. What is your spouse’s VA file number?
(If any)

Yes (If "Yes," answer Item 37b also)
No
38a. Do you live with your spouse?
Yes

(If "Yes," skip to Section X)

(If "No," answer Items 38b through 38d)

38b. What is your spouse’s address?

Street address, rural route, or P.O. Box

City

38c.

Apt. number

State

Tell us why you are not living
with your spouse

ZIP Code

Country

38d. How much do you contribute
monthly to your spouse’s support?

21-526

Page 7

Tell us

SECTION about any
X
previous

You must furnish complete information about all of your and your present spouse’s
previous marriages. If you need additional space, please use Item 52 "Remarks" or
attach a separate sheet of paper.

marriages
NOTE: You should provide copies of divorce decrees or death certificates.
Your previous marriages
39a. How many times have you been married before?
39b. When
were you
married?

39c. Where were
you married?

39d. Who were you
married to?

(city/state or country)

(first, middle initial, last)

39e. When did
your
marriage
end?

mo day yr

39f. Why did your
marriage end?

39g. Where did your
marriage end?

(death, divorce)

(city/state or country)

40f. Why did your
spouse’s marriage end?

40g. Where did your
spouse’s marriage
end?

Your spouse’s previous marriages
40a. How many times has your current spouse been married before?
40b. When
was your
spouse
married?

40c. Where was
your spouse
married?

40d. To whom was your
spouse married?

(city/state or country)

(first, middle initial, last)

mo day yr

40e. When did
your
spouse’s
marriage
end?

(death, divorce)
(city/state or country)

mo day yr

Tell us

SECTION about your
X
other
dependents

Note: You should
provide a copy of
the public record of
birth for each child
or a copy of the
court record of
adoption for each
adopted child.

In this section we want to know whether your parents are financially dependent on you and more
about your dependent children. VA may recognize a veteran’s biological children,
adopted children, and stepchildren as dependents. These children must be unmarried and:
under the age of 18, or
at least 18 but under 23 and pursuing an approved course of education, or
of any age if they became permanently unable to support themselves before reaching
age 18.

..
.

"Seriously disabled" (Item 43h) means that the child became permanently unable to support
himself/herself before reaching age 18. Furnish a statement from an attending physician or other
medical evidence which shows the nature and extent of the physical or mental impairment. If you
need additional space, please use Item 52 "Remarks" or attach a separate sheet of paper.

41. Are your parents financially dependent on you?

Yes

(If "Yes," we may request additional information from you later.)

42. Do you have dependent children?
Yes

(If "No," Skip to Section XI)

21-526

Page 8

SECTION Tell us about your dependent children
X
(Continued)
43a. Name of child

43b. Date and
place
of birth

(first, middle initial, last)

(city/state or country)

43h.
43g.
43I.
18-23 yrs. Seriously
Child
disabled
43c. Social Security
old and in
previously
before
Number
43d.
43e.
43f.
school
married
age 18
Biological Adopted Stepchild

mo day yr
Place:

Tell us about the children listed above who don’t live with you
44a. Name of child

44b. Child’s complete
address

(first, middle initial, last)

Give us
SECTION direct
XI
deposit
information

If benefits are awarded
we will need more information in
order to process any payments
to you. Please read the
paragraph starting with, "All
Federal payments..." and then
either:

44c. Name of person with
whom the child lives (If
applicable)

44d. Monthly amount you
contribute to child’s support

(first, middle initial, last)

All Federal payments beginning January 2, 1999, must be made by electronic funds transfer (EFT), also called
Direct Deposit. Please attach a voided personal check or deposit slip or provide the information requested below
in Items 45, 46 and 47 to enroll in Direct Deposit. If you do not have a bank account we will give you a waiver
from Direct Deposit, just check the appropriate box below in Item 45. The Treasury Department is working on
making bank accounts available to you. Once these accounts are available, you will be able to decide whether
you wish to sign up for one of the accounts or continue to receive a paper check. You may also request a waiver
if you have other circumstances that you feel would cause you a hardship to be enrolled in Direct Deposit. You
may write to: Department of Veterans Affairs, 125 S. Main Street, Suite B, Muskogee OK 74401-7004, and give
us a brief explanation of why you do not wish to participate in Direct Deposit.

45. Account number (Please check the appropriate box and provide that account
number, if applicable)
I certify that I do not have an account with a
Checking
financial institution or certified payment agent
Savings
Account number

1.Attach a voided
check, or

46.

Name of financial institution

2.Answer questions
45-47 to the right.

47.

Routing or transit number

21-526

Page 9

SECTION Give us
XII
your
signature
1. Read the box that
starts, "I certify and
authorize the release
of information."
2. Sign the box that
says, "Your
signature."
3. If you sign with an
"X," then you must
have two people
witness it. They must
then sign the form
and print their names
and addresses also.

SECTION
XIII

I certify and authorize the release of information.
I certify that the statements in this document are true and complete to the best of my knowledge. I
authorize any person or entity, including but not limited to any organization, service provider,
employer, or government agency, to give the Department of Veterans Affairs any information about
me except protected health information, and I waive any privilege that makes the information
confidential.

48. Your signature

49. Today’s date
mo

day

50a. Signature of witness (If claimant
signed above using an "X")

50b. Printed name and address of witness

51a. Signature of witness (If claimant
signed above using an "X")

51b. Printed name and address of witness

52. Remarks (If you need more space to answer a question or have a comment about a specific
item number on this form, please identify your answer or statement by the section and item
number)

Remarks Use this
space for any
additional
statements
that you would like
to make concerning
your application for
compensation.

IMPORTANT
Penalty: The law
provides severe
penalties which include
fine or imprisonment, or
both, for the willful
submission of any
statement or evidence of
a material fact, knowing
it to be false, or for the
fraudulent acceptance of
any payment which you
are not entitled to.

21-526

Page 10

OMB Approved No. 2900-0001
Respondent Burden: 5 minutes

AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO THE
DEPARTMENT OF VETERANS AFFAIRS (VA)
Respondent Burden: We need this information to obtain your treatment records. Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information and complete
this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the
OMB Internet Page at www.whitehouse.gov/library/omb/OMBINVC.html#VA. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.

IF YOU HAVE ANY QUESTIONS ABOUT THIS FORM, CALL VA TOLL-FREE AT 1-800-827-1000
(TDD 1-800-829-4833 FOR HEARING IMPAIRED)
SECTION I

VETERAN/CLAIMANT IDENTIFICATION

1. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

2. VETERAN’S VA FILE NUMBER

3. CLAIMANT’S NAME (If other than Veteran)

4. VETERAN’S SOCIAL SECURITY NUMBER

LAST NAME, FIRST, MIDDLE

6. CLAIMANT’S SOCIAL SECURITY NUMBER

5. RELATIONSHIP OF CLAIMANT TO VETERAN

SECTION II

SOURCE OF INFORMATION

7A. LIST THE NAME AND ADDRESS OF THE SOURCE SUCH AS A
PHYSICIAN, HOSPITAL, ETC.(Include ZIP Codes, and also a telephone
number, if available)

7B. DATE(S) OF TREATMENT,
HOSPITALIZATIONS OFFICE
VISITS, DISCHARGE FROM
TREATMENT OR CARE, ETC.
(Include month and year)

7C. CONDITION(S)
(Illness, injury, etc.)

8. COMMENTS:

YOU MUST SIGN AND DATE THIS FORM AT THE BOTTOM OF PAGE 2 AND CHECK THE APPROPRIATE
BLOCK IN ITEM 9C.
VA FORM
NOV 2006

21-4142

EXISTING STOCKS OF VA FORM 21-4142, MAY 2004,
WILL BE USED.

PAGE 1

SECTION III

CONSENT TO RELEASE INFORMATION

READ BOTH PARAGRAPHS CAREFULLY BEFORE SIGNING. YOU MUST CHECK THE
APPROPRIATE STATEMENT UNDERLINED IN PARENTHESES IN PARAGRAPH 9C.
9A. PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the
collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA
benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and
Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is voluntary. However, if the information including your Social Security
Number (SSN) is not furnished completely or accurately, the health care provider to which this authorization is addressed may not be able to identify and locate your
records, and provide a copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your
claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an
individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in
effect.

9B. I, the undersigned, hereby authorize the hospital, physician or other health care provider or health plan shown in Item 7A, to release any information that may have
been obtained in connection with a physical, psychological or psychiatric examination or treatment, with the understanding that VA will use this information in determining
my eligibility to veterans benefits I have claimed. I understand that the health care provider or health plan identified in Item 7A who is being asked to provide the Veterans
Benefits Administration with records under this authorization may not require me to execute this authorization before it will, or will continue to, provide me with treatment,
payment for health care, enrollment in a health plan, or eligibility for benefits provided by it. I understand that once my health care provider sends this information to VA
under this authorization, the information will no longer be protected ay the HIPPA Privacy Rule, but will be protected by the Federal Privacy Act, 5 USC 552a, and VA may
disclose this information as authorized by law. I also understand that I may revoke this authorization, at anytime (except to the extent that the health care provider has
already released information to VA under this authorization) by notifying the health care provider shown in Item 7A. Please contact the VA Regional Office handling your
claim or the Board of Veterans’ Appeals, if an appeal is pending, regarding such action. If I do not revoke this authorization, it will automatically end 180 days from the date
you sign and date the form (Item 10C).

9C. I
(AUTHORIZE)
(DO NOT AUTHORIZE) the source shown in Item 7A to release or disclose any information or
records relating to the diagnosis, treatment or other therapy for the condition(s) of drug abuse, alcoholism or alcohol abuse, infection
with the human immunodeficiency virus (HIV), sickle cell anemia or psychotherapy notes. IF MY CONSENT TO THIS
INFORMATION IS LIMITED, THE LIMITATION IS WRITTEN HERE:

10A. SIGNATURE OF VETERAN/CLAIMANT OR LEGAL
REPRESENTATIVE

10B. RELATIONSHIP TO VETERAN/CLAIMANT (If other than
self, please provide full name, title, organization, city, State
and ZIP Code. All court appointments must include docket
number, county and State)

10D. MAILING ADDRESS (Number and Street or rural route, city, or P.O. State and ZIP Code)

10C. DATE

10E. TELEPHONE NUMBER (Include Area Code)

The signature and address of a person who either knows the person signing this form or is satisfied as to that person’s identity is requested below.
This is not required by VA but may be required by the source of the information.
11A. SIGNATURE OF WITNESS

11B. DATE

11C. MAILING ADDRESS OF WITNESS

PAGE 2

File Type	application/pdf
File Modified	0000-00-00
File Created	0000-00-00