Form VA Form 21-526 and VA Form 21-526 and Veterans Application for Compensation and/or Pension; Au

GENERAL INSTRUCTIONS
FOR VETERAN'S APPLICATION FOR COMPENSATION AND/OR PENSION,
VA FORM 21-526, PARTS A,B,C, & D

What's in these instructions?

Use these instructions to help you complete VA Form
21-526 Parts A, B, C, and D to apply for compensation
and/or pension. The "General Instructions" consist of
the following four sections:
Section 1: Preparing your application. This section
gives you information you should consider before you
file your claim. It tells you why you should use VA
Form 21-526 and then helps you decide what you are
applying for, which parts to use, and which items you
will need to fill out.
Section 2: Completing your VA Form 21-526. This
section helps you complete your VA Form 21-526. It
has specific advice for difficult parts and tells you where
to send your forms after you've filled them out.
Section 3: Finding answers to other questions. This
section tells you more about other issues that you may
have questions about.
Section 4: Explanation of the Privacy Act and
Respondent Burden: This section tells you what the
Privacy Act is and explains how VA uses the requested
information. It also explains the respondent burden
which is an estimate of how long it will take you to fill
out this form.

INSIDE THESE INSTRUCTIONS
Pg. 2 Section 1: Preparing your application
Pg. 2 Checklist: Which parts of VA Form 21-526
should you use?
Pg. 3 Checklist: Things you'll need to prepare for
filling out your application
Pg. 4 Section 2: Completing your application
Pg. 5 Where do you send your application?
Pg. 5 Tips for filling out your VA Form 21-526
Pg. 6 Section 3: Finding answers to other
questions
Pg. 7 Section 4: Explanation of the Privacy Act
and Respondent Burden
Before you start . . .
Where can I get help filling out my application?
You can contact a County or National Veterans'
Service Organization to help you complete the
form, or
VA FORM
JAN 2004

21-526

You can ask VA to help you fill out the form by
calling or visiting a regional office. Someone in the
regional office will help you complete the form. If
you go to a regional office, you should have all the
materials that are listed on page 3 under "Checklist:
Things you will need to prepare for filling out your
application." Before you call or go to the regional
office, make sure you gather the necessary
materials and complete as much of the form as you
can.
How can I contact VA if I have questions?
If you have questions about this form, how to fill it out,
or about benefits, you can contact VA in the following
ways.
By mail:
You can locate the address of the closest regional
office in your telephone book blue pages
under "United States Government, Veterans"
By telephone:
Please call one of the following telephone numbers:
1-800-827-1000
1-800-829-4833 (Hearing Impaired TDD line)
By Internet:
http://www.vba.va.gov/benefits/address.htm
Social Security Benefits
The Social Security and Supplemental Security Income
disability programs are the largest of several Federal
programs that provide assistance to people with
disabilities. While these two programs are different in
many ways, both are administered by the Social Security
Administration (SSA) and only individuals who have a
disability and meet medical criteria may qualify for
benefits under either program.
How can I contact SSA if I have questions?
If you have a question, call the SSA toll-free phone
number at 1-800-772-1213, Monday through Friday,
from 7AM to 7PM. If you have a touch-tone phone,
recorded information and services are available 24 hours
a day, including weekends and holidays. People who are
deaf or hard of hearing may call the toll-free TTY
number, 1-800-325-0778, between 7 a.m. and 7 p.m. on
Monday through Friday. Please have your Social
Security number handy when you call.
By mail:
You can locate the address of the closest SSA
office in your telephone book blue pages
under "United States Government, Social
Security Administration"
By Internet:
http://www.ssa.gov/

SUPERSEDES VA FORM 21-526, APRIL 2003, WHICH
WILL NOT BE USED.

General Instructions

page 1

Section 1: Preparing your application
What do I use VA Form 21-526 for?
Use VA Form 21-526 to apply for compensation and/or
pension benefits.
You should apply for compensation benefits if any of
the following are true:
You were injured while you were in the service.
You were seriously ill while you were in the
service, and you believe you have continuing
problems.
You developed a mental or physical condition that
may be related to your military service.
You are permanently and totally disabled and you
believe it is because of your military service.
You should apply for pension benefits if all of the
following are true:
You are permanently and totally disabled (but not
as a result of your military service).

VA Form 21-526 has four parts. Everyone has to fill out
Part A of the form. You fill out some or all of the other
parts depending on the benefits you are applying for. Once
you have decided what you are applying for, find out which
parts you need to use by reading through the check list
below called "Which Parts of VA Form 21-526 Should You
Use?"
What can I do to help get my application processed
faster?
VA will make reasonable efforts to help you get this
evidence. You can help us by telling us about all the
evidence that supports your claim. Evidence is information
that confirms that what you are telling us is correct. For
instance, if you are claiming service connection for a
certain disability, we will help you by requesting medical
records from your doctor or from VA that show you have
this disability. We will also help you by requesting records
from other Federal or non-Federal agencies or companies.
We will request your service medical records in claims for
compensation.

You served on active duty during a wartime
period.
Your income is limited.

CHECK LIST: WHICH PARTS OF VA FORM 21-526 SHOULD YOU USE?
Look at the table below to find out which parts of VA Form 21-526 you should
use to apply for different benefits.

You must fill out:
If you are
applying for:

VA Form 21-526,
Part A: General
Information

VA Form 21-526,
Part B: Compensation

VA Form 21-526, VA Form 21-526,
Part C: Dependency Part D: Pension

Compensation
only
Pension Only
Compensation
and Pension
General Instructions

page 2

CHECKLIST: THINGS YOU'LL NEED TO PREPARE FOR FILLING OUT YOUR
APPLICATION
When you fill out this
VA Form. . .
21-526 Part A:
General Information

You'll need this information ready to answer
questions. . .
Active Duty Information
dates and places you entered and left
mailing addresses of units you served in

You should attach these
pieces of information. . .
An original or certified copy of DD214
or other separation papers for all
periods of service

Reserve Duty and National Guard Duty information
dates and places you entered and left
mailing addresses of units you served in
List of military benefits you receive and amounts
21-526 Part B:
Compensation

21-526 Part C:
Dependency

List of disabilities you are claiming, including
treatment dates in service
name and address of the medical facilities
where you have been treated after service
Information about any environmental exposures or
events that caused the disabilities you are claiming,
including dates they happened

An original or copies of all service
medical records you have

Information about your current spouse, including his/
her Social Security number (and VA file number if
he/she is a veteran)

Copies of your marriage certificate and
all divorce decrees (May be required in
some cases)

Information about you and your spouse's previous
marriages including dates and places of those
marriages and the dates and places those marriages
ended
Information about the children who live with you,
including their names, Social Security numbers, dates
and places of birth

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

Medical records you have showing you
currently have this disability
Medical records you have indicating
that the disability was caused by or
happened during your active service

Copies of the court records for adoption
for each adopted child

Information about children not living with you,
including their names, dates and places of birth,
Social Security numbers, and amounts that you
contribute in child support for them
21-526 Part D:
Pension
Note: If you are a
veteran who is age 65
or older you DO
NOT have to submit
medical evidence
with your application.

Information about your training and employment
history for the past year, including
name and address of employers
beginning and ending dates of employment
Information about your nursing home, if you live in
one
Information about your net worth and your
dependents' net worth
Information about your recurring income and your
dependents' recurring income
Information about income you and your dependents
expect to receive in the next 12 months

Current medical evidence telling us
about your disabilities
If you are in a nursing home, attach a
statement signed by an official of the
nursing home that includes
the date you were admitted to a
nursing home
your level of care in the nursing
home
Your nursing home payment status,
which is Medicaid coverage or private
pay

General Instructions

page 3

Section 2: Completing your application
You will find instructions on each part of VA Form
21-526 to help you fill them out. However, there still
might be some areas of the forms that are difficult. In
this section, we've included the answers to some
common problems that claimants have with the forms.
They should help you fill out your forms more quickly
and easily.

by these records, and the condition for which you were
treated in the case of medical records. If you received
treatment from a military health care facility after your
discharge from service, private physician,or any other
health care provider, complete the attached VA Form
21-4142, Authorization and Consent to Release
Information to the Department of Veterans Affairs (VA).
We will use this form to request these records.

VA Form 21-526, Part A: General Information
Section III
What is the Gulf War registry? VA has a registry of
veterans who served in the Gulf War theater of
operations. The information in this registry will be
shared only 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 your nearest VA
medical facility to request an examination.
Section VII
Should I waive military retired pay for VA
compensation? If you currently receive military retired
pay, you should be aware that we will reduce your
retired pay by the amount of any compensation that you
are awarded. However, this is to your advantage
because VA compensation is not taxable and most
retired pay is taxable. Based on your application, if
you are awarded compensation, we will tell the Military
Retired Pay Center to reduce your retired pay by the
amount of compensation you have been awarded. If you
do not want this to happen, you must sign Item 21e of
VA Form 21-526, Part A to let us know.
VA Form 21-526, Part B: Compensation
Section I
What kind of disabilities should I list? When possible,
try to list the actual disease and medical condition that a
doctor has diagnosed. Be as specific as you can.
Do I have to include any records with this claim
form?
If you have records that support your claim you should
attach them to this claim form. 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. On this form you must tell us the
name and address of the person, company or agency that
has these records, the approximate time frame covered

VA Form 21-526, Part C: Dependency
Section III
Who can I count as a dependent child? VA recognizes
your biological children, adopted children, and
stepchildren as dependents. But these children must be
unmarried and:
be under the age of 18, or
be at least 18 but under 23 and pursuing an
approved course of education, or
have become permanently unable to support
themselves before reaching the age of 18.
VA Form 21-526, Part D: Pension
Section IV
What do you mean by "net worth"? Your net worth is
the market value of all the interest and rights you have
in any kind of property. However net worth does not
include your single family dwelling unit and a
reasonable lot area. Net worth also does not include the
personal things you use everyday like your vehicle,
clothing, and furniture.
NOTE: If you are a veteran who is age 65 or older, you
DO NOT have to submit medical evidence with your
application.
What do I do when I have finished my application?
1. Make sure you sign and date VA Form 21-526, Part
A. You must provide your signature in Section IX, Item
25 of this form. If you don't sign the form, VA will
return it for you to sign, and it will take longer for us to
process it.
2. Attach any materials that support and explain your
claim. Be sure to look at the checklist on page 3 of
these instructions to make sure that you have attached
all important pieces of information to your application.
General Instructions

page 4

Section 2: Completing your application
(Continued)
3. You may complete the attached VA Form
21-4142, Authorization and Consent to Release
Information to the Department of Veterans Affairs (VA)
with your VA Form 21-526 if you want help getting
additional records. By signing VA Form 21-4142, you
authorize any doctors, hospitals, or caregivers that have
treated you to release information about your treatment
to the VA. Be sure to sign and date the form. Make as
many copies of VA Form 21-4142 as you need to give
authorization to all the doctors, medical facilities, or
caregivers that treated you. You do not need to complete
this form for any treatment you received at a VA facility.
4. Make a photocopy of your application and everything
that you submit to VA. By having copies, you will be
prepared if VA has a question about your application.

Where do I send my application?
Mail the original application and your supporting
materials to the closest VA office. You can find the
address in your local telephone book or at the VBA
internet web site: http://www.vba.va.gov/benefits/
address.htm
What if I need to change or add information to my
application after I give it to VA?
If you find that you need to change or add information
to your application, contact VA where you submitted
your application immediately. In a letter, make sure you
specify:
your name,
claim number if you know it (or Social
Security number if you don't know the claim
number), and
the item number you want to change or add
to.

TIPS FOR FILLING OUT
YOUR VA FORM 21-526
ATTACHING FORMS AND OTHER
INFORMATION:
Throughout this form, you will be asked to
attach certain pieces of information to the form
itself. For example, you are asked to attach a
DD214 to your Form 21-526, Part A. The
DD214 needs to be an original or certified
copy, other documents do not. To get a
certified copy, you can take your original to
the courthouse and have it copied and signed
by an official of the court. A VA employee
can also "certify" a copy for you.
ANSWERING QUESTIONS COMPLETELY:
Remember that the more questions you answer,
the faster your claim can be processed. Try to
answer every question that applies to your
situation and fill out as much of the form as you
can. The list below answers some questions that
you might be wondering about:
What if my answer to a question is "none" or
"0"? Write that as your answer.
What if I need to include an address that is
not in the United States? Make sure that you
include the name of the country in your
answer.
What if I need more space to answer a
question? You can use Part A of the 21-526,
page 5, Item 29 "Remarks" or attach a sheet
of paper to your form. Write "Continuation
of answers" at the top of the page, your
name, and your VA claim number. If this is
your first claim, you will not have a VA
claim number, so write your Social Security
number instead. For each question that you
need more room, write "Continuation of
Item" and the item number. For example, if
you need more room to answer Item 16 on
VA Form 21-526, part A, write
"Continuation of Item 16, VA Form 21-526,
Part A."
KEEPING RECORDS: It is important that you
keep a copy of all the forms you fill out and
give to VA. This way you will have your
own complete record to refer to.
SIGNING FORMS: Be sure to sign every form
you fill out before you send it to us.

General Instructions

page 5

Section 3: Finding answers to other
questions
What can you tell me about VA benefits and how VA
decides 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 the regular aid and attendance of another
person.
VA pays disability pension to veterans who:
are permanently and totally disabled but
not as a result of military service or
the veteran's own willful misconduct
served during:
Mexican Border Period
World War I
World War II
Korean Conflict
Vietnam Era
Gulf War
VA pays disability pension based on the amount of
income that the veteran and family received and the
number of dependents in the family. This is based on
law. VA must include as income all sources that federal
law specifies. You can find out what the current income
limitations and rates of benefits are by contacting your
nearest VA office. See page 1, "How can I contact VA if
I have a question?" for ways to contact us.
VA may pay a higher rate of disability pension to a
veteran who is a patient in a nursing home, otherwise
needs regular aid and attendance, or who is permanently
confined to his or her home because of a disability.

An agent recognized by VA or a licensed lawyer.
Agents and attorneys can charge you for
services that you get from them only after the
Board of Veterans Appeals (BVA) gives you their
final decision about your application. That means
you can use an attorney during any stage of your
application for benefits. However, the agent or
attorney cannot charge 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 closest VA 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
VA Form 21-22A, Appointment of Individual as
Claimant's Representative
What if I believe that VA has made an error in
processing or deciding on my benefits?
You can ask for a personal hearing at any time during
the processing of your claim. That means you can ask
for the hearing while VA is processing your claim or
after VA has made a decision. You should contact the
nearest VA office and tell them that you want a personal
hearing on your case. Someone in the local VA office
will arrange a time and a place for your hearing. At this
hearing, you can bring witnesses. VA will record
whatever you and your witnesses say during the hearing
and include it in the official record. VA will furnish the
hearing room and officials, 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. After your claim has been decided you will
have one year from the date of notice to appeal that
decision.

I would like help in understanding the process of
getting my benefits. What can I do?
You can ask someone to act as your representative. A
representative can be:
An accredited member of an accredited
organization or other service organization that
the Secretary of Veterans Affairs recognizes.
General Instructions

page 6

Section 4: Explanation of the Privacy Act and Respondent Burden
PRIVACY ACT INFORMATION: No allowance of compensation or pension may be granted unless this form is
completed fully as required by law (38 U.S.C. 5101). The responses you submit are considered confidential (38 U.S.C.
5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the
disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records,
58VA21/22 Compensation, Pension, Education, and Rehabilitation Records - VA. The requested information is
considered relevant and necessary to determine maximum benefits under the law. Information submitted is subject to
verification through computer matching programs with other agencies. VA may make a "routine use" disclosure for:
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. Your
obligation to respond is required in order to obtain or retain benefits. Information that you furnish may be utilized in
computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to
receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any
benefit program administered by the Department of Veterans Affairs.
Income and employment information: The 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.
Social Security information: You are required to provide the Social Security number(s), requested under 38 U.S.C.
5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically, may
disclose them for the purposes stated above.
Respondent Burden: VA may not conduct or sponsor, and respondent is not required to respond to this collection of
information unless it displays a valid OMB Control Number. Public reporting for this collection of information is
estimated to average 1 hour and 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. If you have comments regarding this burden estimate or any other aspect of this collection of information,
call 1-800-827-1000 for mailing information on where to send your comments.

General Instructions

page 7

OMB Approved No. 2900-0001
Respondent Burden: 1 hour 30 minutes
(DO NOT WRITE IN THIS SPACE)

VETERAN'S APPLICATION FOR COMPENSATION AND/OR PENSION,
VA Form 21-526, Part A: General information
Please read the attached "General Instructions" before you fill out this form.
1. What are you applying for? If you are unsure please refer to the "General Instructions" page 2
SECTION Tell us
Section 1: Preparing your application
what
you
I
are
applying
for

Compensation

Fill out Part A of VA Form 21-526 and Parts B and C

Pension

Fill out Part A of VA Form 21-526 and Parts C and D

Check the box that
says what you are
applying for. Be sure to
complete the other
Parts you need.

Fill out Part A of VA Form 21-526 and Parts B, C
and D
2a. Have you ever filed a claim with VA
2b. I filed a claim for
No (If "No," skip Item 2b and go to Item 3)
Compensation
Pension

SECTION Tell us
about
II

3. What is your name?

We need information
about you to process
your claim faster.

4. What is your Social Security number?

Compensation and Pension

(If "Yes," provide file number below)

Yes

First

you

Other

(Go to 2b)

Middle

Last

Suffix (If applicable)

5. What is your sex?
Male

6a. Did you serve under another name?

Female

6b. Please list the other name(s) you served under

Yes (If "Yes," go to Item 6b)
No
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 block
29 "Remarks." Also
in block 29, give us
the date you think
you will be at the
new address.

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

(If "No," go to Item 7)

7. What is your address?
Street address, Rural Route, or P.O. Box
City

Apt. number

State

8. What are your telephone numbers?

ZIP Code

Country

9. What is your e-mail address?

Daytime
Evening
10. What is your date of birth?

11. Where were you born? (City, State and Country)

12a. Are you receiving disability benefits
from the Office of Workers'
Compensation (OWCP)?

12b. When was the claim filed?

Yes

No

12c. What disability are you receiving benefits for?

( If "Yes," answer 12b and 12c also)

13a. What is the name of your nearest
relative or other person we could
contact if necessary?

13b. What is his/her telephone number?
Daytime
Evening

13c. What is this person's address?

VA FORM
JAN 2004

21-526

13d. How is this person related to you?

SUPERSEDES STOCKS OF VA FORM 21-526, APR 2003
WHICH WILL NOT BE USED

21-526, Part A

page 1

SECTION Tell us
about
III

your
active
duty
1. Enter complete
information for all
periods of service.
If more space is
needed use Item 29
"Remarks."
2. Attach your
original DD214 or a
certified copy to this
form. (We will return
original documents to
you.)

14a. I entered active
service the first time. . .
mo

day yr

mo

day yr

14d. I left this active
service. . .

14h. I entered
my second period of
active service. . .
mo

day yr

mo

day yr

14k. I left this active
service. . .

14b. Place:

14c. My service number was . . .

14e. Place:

14f. Branch of
Service

14i. Place:

14j. My service number was . . .

14l. Place:

14m. Branch of
Service

15a. Did you serve in Vietnam?
Yes
The VA has a registry of
veterans who served in
the Gulf War. This area
has also been called the
"Persian Gulf." 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 16b. For
more information about
the registry, see page 4
of the General
Instructions for VA Form
21-526.

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

16a. Were you stationed in the Gulf after
August 1, 1990?

to

No

yr

mo day

yr

16b. Do you want to have medical and other
information about you included in the
"Gulf War Veterans' Health Registry?"
Yes

No

(If "Yes," answer Item 16b also)

17a. Have you ever been a prisoner of
war?
Yes

17b. What country or government imprisoned
you?

No

(If "Yes," answer Items 17b, 17c, and 17d also)

from

17d. What was the name of the camp or sector
and what are the names of the city and
country near its location?

to

mo

your
reserve
duty

from

mo day

17c. When were you confined?

SECTION Tell us
about
IV

14n. Grade, rank,
or rating

15b. When were you in Vietnam?

No

Yes

14g. Grade, rank,
or rating

day yr

mo

day yr

18a. Are you currently assigned to an
active reserve unit?
Yes

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

No

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

18c. Were you previously assigned to an
active reserve unit within the last 2
years?
Yes

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

No

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

21-526, Part A

page 2

SECTION (Continued)
IV
Tell us
about your
reserve
duty

Instructions 18g-18k
If you are currently or have
ever been a full time reservist
for operational or support
duty,
1. Complete 18g-18k for
that service only.
2. Attach proof of reserve
service.

18e. Do you have an inactive reserve
obligation? (You perform no active duty,
but you could be activated if there was a
national emergency)
Yes

If your disability occurred or
was aggravated during any
period of reserve duty,
1. Complete 18l-18p for the
period when your
disability occurred.
2. Attach proof that your
disability occurred during
reserve service.

SECTION Tell us
about
V

your
National
Guard
duty

Don't Know

mo day

yr

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

18g. I entered reserve service. . .
Place:
mo

18j. Branch of
service

18k. Grade, rank,
or rating

day yr

18l. I entered reserve service. . .
Place:
mo

18h. My service number was . . .

day yr

18i. I left reserve service. . .
Place:
mo

Instructions 18l-18p

No

18f. What is your reserve obligation
termination date?

18m.My service number was . . .

day yr

18n. I left reserve service. . .
Place:
mo

18p. Grade, rank,
or rating

day yr

19a. Are you currently a member of
the National Guard?
Yes

18o. Branch of
service

No

19b. What is the name, mailing address, and
telephone number of your current unit?

Not Assigned

(If "Yes," answer Item 19b also)

19c. Were you previously assigned to a
guard unit within the last 2 years?
Yes

19d. What is the name, mailing address, and
telephone number of that unit?

No

(If "Yes," answer Item 19d also)

Instructions 19e-19i
If you were activated to
Federal Active Duty under the
Authority of Title 10, United
States Code,
1. Complete 19e-19i for that
service only.
2. Attach proof of this
Federal Active Duty.

19e. I entered Federal Active Duty. . .
Place:
mo

If your disability occurred or
was aggravated during any
period of guard duty,
1. Complete 19j-19n for the
period when your
disability occurred.
2. Attach proof that your
disability occurred during
National Guard Service.

day yr

19g. I left Federal Active Duty. . .
Place:
mo

Instructions 19j-19n

19f. My service number was . . .

19h. Branch of
service

19i. Grade, rank,
or rating

day yr

19j. I entered National Guard. . .
Place:
mo

19k. My service number was . . .

day yr

19l. I left National Guard. . .
Place:
mo

19m. Branch of
service

19n. Grade, rank,
or rating

day yr

21-526, Part A

page 3

SECTION
VI

Tell us
about
your
travel
status

20a. Were you injured 20b. When did
20c. Where did 20d. Where were you
treated? (Provide name
while traveling to or
your injury happen? your injury
and address of doctor's
from your military
happen?
assignment?
(City,State,Country) office, hospital, etc.)

(If "Yes," answer Items 20b
thru 20e and Section I of Part
B: Compensation)

Yes
Tell us

SECTION about
VII
your

military
benefits

When you file this
application, you are
telling us that you want to
get VA compensation
instead of military retired
pay. If you currently
receive military retired
pay, you should be aware
that we will reduce your
retired pay by the amount
of any compensation that
you are awarded. VA will
notify the Military Retired
Pay Center of all benefit
changes.
You must sign 21e if you
want to keep getting
military retired pay
instead of VA
compensation.
Please see page 4 of the
General Instructions for
VA Form 21-526.
If you have gotten both
military retired pay and
VA compensation, some
of the amount you get
may be recouped by VA,
or in the case of VSI, by
the Department of
Defense.

mo

20e. What
agency did you
file an accident
report with?

day yr

No
21b. What branch of service 21c. What is the
is paying or will pay
monthly amount?
your retired or
retainer pay?

21a. Are you receiving or will you
receive retired or retainer pay that
is based on your military service?
Yes
No

$

(If "Yes," answer Items 21b thru 21f. If "No," skip
to Item 22)

21d. What is your retirement based on?
Length of service

Disability

TDRL (Temporary Disability Retired List)

21e. Sign here if you want to receive military retired pay instead of VA compensation

21f. Have you received or will you receive any of the following military benefits?
(Please check the appropriate boxes and tell us the amount)

Benefit

Amount

(1)

Lump Sum Readjustment Pay

$

(2)

Separation pay under 10 USC 1174

$

(3)

Special Separation Benefit (SSB)

$

(4)

Voluntary Separation Incentive (VSI)

$

(5)

Disability Severance Pay (name of disability

)

$

(6)

Other (tell us the type of benefit

)

$

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 22, 23 and 24 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 box below in Item 22. 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 can also request a waiver
if you have other circumstances that you feel would cause you a hardship to be enrolled in Direct Deposit. You
can write to: Department of Veterans Affairs, 125 S. Main Street Suite B, Muskogee OK 74401-7004, and give
If benefits are
awarded we will need more us a brief description of why you do not wish to participate in Direct Deposit.

SECTION Give us
direct
VIII
deposit
information

information in order to
process any payments to
you. Please read the
paragraph starting with,
"All federal payments..."
and then either:

22. Account number (Please check the appropriate box and provide that account number, if applicable)
Checking
Savings
Account number

1. Attach a voided
check, or

23. Name of financial institution

2. Answer questions
22-24 to the right.

24. Routing or transit number

I certify that I do not have an account with a financial
institution or certified payment agent

21-526, Part A

page 4

SECTION Give us
your
IX

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 2 people you
know witness you as
you sign. They must
then sign the form and
print their names and
addresses also.

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 which makes the information
confidential.
25. Your signature
26. Today's date

27a. Signature of witness (If claimant
signed above using an "X")

27b. Printed name and address of witness

28a. Signature of witness (If claimant
signed above using an "X")

28b. Printed name and address of witness

29. Remarks (If you need more space to answer a question or have a comment about a specific item

SECTION
X

number on this form
please identify your answer or statement by the part and item number). (See page 5 "Tips For Filling Out Your VA Form
21-526.")

Remarks - Use this
space for any
additional
statements
that you would like
to make concerning
your application for
Compensation
and/or Pension
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, Part A

page 5

VA Form 21-526, Part B: Compensation
Use this form to apply for compensation. Remember that you must also fill out a VA Form 21-526, Part A: General
Information, for your application to be processed. Be sure to write your name and Social Security number in the space
provided on page 2.

SECTION Tell us
about your
I
disability

1. What disability are
you claiming?

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.
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 sources before, during, and
after your service.

2. When did
your
disability
begin?

mo day yr

mo day yr

mo day yr

mo day yr

mo day yr

mo day yr

mo day yr

mo day yr

mo day yr
VA FORM
JAN 2004

21-526

3. When were you
treated?

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

from

to

mo day yr

mo day yr

4a. What medical
facility or doctor
treated you?

4b. What is the address of
that medical facility or
doctor?

21-526 , Part B

page 1

SECTION Tell us if
any of the
II

disabilities
you listed
on Page 1
were
because of
exposures

5a. Were you exposed to Agent
Orange or other herbicides?
Yes

No

6a. Were you exposed to asbestos?
Yes

No

(If "Yes," answer Item 6b and 6c also)

7a. Were you exposed to mustard gas?
Yes

No

(If "Yes," answer Item 7b and 7c also)

8a. Were you exposed to ionizing
radiation?
Yes

5b. What is your disability? 5c. In what country were
you exposed?

6b. What is your disability?
6c. When and how were you exposed?
7b. What is your disability?
7c. When and how were you exposed?
8b. What is your
disability?

8c. When was your
last exposure?

No

(If "Yes," answer Items 8b, 8c, and 8d also)

8d. How were you exposed to
radiation?

mo day

yr

Atmospheric testing
Nagasaki/Hiroshima
Other, describe

9a. Were you exposed to an
environmental hazard in the
Gulf War?
Yes

9b. What is your
disability?

9c. What was the
hazard?

10b. When was the
exam?

10c. Where did the
exam occur?

No

(If "Yes," answer Items 9b and 9c also)

10a. Did you have a separation or
retirement physical examination?
Yes

No

(If "Yes," answer Items 10b and 10c also)

SECTION Tell us
how
III

mo day

yr

11. Explanation

your
disabilities
listed on
Page 1
are related
to your
military
service

Your Name

Your Social Security Number

21-526 , Part B

page 2

VA Form 21-526, Part C: Dependency

Use this form to tell us more about your dependents. Remember that you must also fill out a VA Form 21-526, Part A:
General Information, Part B and/or Part D, for your application to be processed. Be sure to write your name and Social
Security number in the space provided on page 3.

SECTION Tell us
about
I

your
marriage

NOTE: You
should provide
a copy of your
marriage
certificate

1. What is your marital status?
Married

Surviving Spouse

Divorced

Never Married

(If your spouse died, you are "divorced," or "never married" skip to Section III beginning on page 2)

3. Where did you get married?

2. When were you married?

(city/state or country)

month day

year

4. What is your
spouse's name?
First

Middle

5. What is your spouse's birthday?

month day

6. What is your spouse's Social Security
number?

year

7a. Is your spouse also a veteran?
Yes

Last

7b. What is your spouse's VA file number (If
any)?

No

(If "Yes," answer Item 7b also)

8. Do you live with your spouse?
Yes (If "Yes," go to Item 12)
No

(If "No," go to Item 9)

9. What is your spouse's address?
Street address, Rural Route, or P.O. Box
City

Apt. number

State

Zip code

10. Tell us why you are not living
with your spouse

Country

11. How much do you contribute monthly
to your spouse's support?

$
12. How were you married?
a.
b.

VA Form
JAN 2004

21-526

Ceremony by a clergyman or other
authorized public official

c.

Tribal

d.

Proxy

Common-law

e.

Other (please describe in the space below)

21-526, Part C

page 1

SECTION Tell us
about any
II

previous
marriages

NOTE: You should provide copies
of divorce decrees or death
certificates.

In the table below, tell us about:
Your previous marriages, and
Your spouse's previous marriages

Your previous marriages
13a. How many times have you been married before?
13b. When were
you
married?

13e. When did
your
marriage
(city/state or country) (first, middle initial, last)
end?

13c. Where were
you married?

13d. Who were you
married to?

mo day yr

mo day yr

mo day yr

mo day yr

13f. Why did your
marriage end?

13g. Where did your
marriage end?

14f. Why did your
spouse's
marriage end?

14g. Where did your
spouse's
marriage end?

(death, divorce)

(city/state or country)

Your spouse's previous marriages
14a. How many times has your current spouse been married before?
14b. When was
your spouse
married?

14c. Where was
your spouse
married?

14d. Who was
your spouse
married to?

14e. When did
your
spouse's
(city/state or country) (first, middle initial, last)
marriage
end?

mo day yr

mo day yr

mo day yr

mo day yr

SECTION Tell us
about your
III
other
dependents

(city/state or country)

In this section we want to know whether your parents are financially dependent on you (Question
15) and more about your dependent children. VA may recognize a veteran's biological children,
adopted children, and stepchildren as dependent. These children must be unmarried and:
be under the age of 18, or
be at least 18 but under 23 and pursuing an approved course of education, or
have become permanently unable to support themselves before reaching the age of 18.
15.

Are your parents financially dependent on you?
Yes

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.

(death, divorce)

16.

No

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

Do you have dependent children?

17. How many dependent
children do you have?

Yes
(If "No," Skip Items 17-21f). Go to the bottom Give us more information about these children in the
of page 3 and write your name and Social
tables on the next page (Items 18 through 21f)
Security number)

No
21-526, Part C

page 2

SECTION III

Tell us about your dependents (continued)

18a. What is the name
18b. Date
of your unmarried and place
of birth
child(ren)?
(first, middle initial, last)

(city/state or country)

18c. Social
Security Number

20b.
20a.
20c.
19a.
19b.
19c.
18-23 yrs. Seriously
Child
Biological Adopted Stepchild old and in disabled previously
school before age married
18

mo day yr
Place:

mo day yr
Place:

mo day yr
Place:

mo day yr
Place:

Tell us about your dependents listed above who don't live with you
21a. Do all the children listed above live with you?
Yes

(If "Yes," skip Items 21b thru 21f and write
your name and Social Security number
below

No

(If "No," complete Item 21b and the table
below (Items 21c -21f) and write your
name and Social Security number below)

21c. What is the name
of your child?

(first, middle initial, last)

21b.

21d. What is your child's
complete address?

How many of the children do not
live with you?

21e. What is the name of
the person your child
lives with (If applicable)?

21f. How much do you
contribute each month to the
support of your child?

(first, middle initial, last)

$

$

$

$
Your name

Your Social Security Number
21-526, Part C

page 3

VA Form 21-526, Part D: Pension
Use this form to apply for pension. Remember that you must also fill out a VA Form 21-526, Part A: General Information, for
your application to be processed. Be sure to write your name and Social Security number in the space provided on page 4.

SECTION Tell us
about your
I

1a. What disability(ies) prevent you from
working?

1b. When did the disability(ies) begin?

disability
and
background
month day year

Complete this section if
you are claiming
pension because of
permanent and total
disability not caused by
your military service.

2.

Are you claiming a special monthly
pension because you need the regular
assistance of another person, are
blind, nearly blind, or having severe
visual problems, or are housebound?
Yes

No

3b. Tell us the dates of the recent
hospitalization or care.

Attach current medical
evidence showing that
you are permanently
and totally disabled.

3a. Are you now, or have you recently
been hospitalized or given outpatient
or home-based care?
Yes

No

(If "Yes," answer Items 3b and 3c also)

3c. What is the name and complete mailing
address of the facility or doctor?

Began
month day year
Ended
month day year

Note: If you are a
veteran who is age 65
or older, or determined
to be disabled by the
Social Security
Administration, you
DO NOT have to
submit medical
evidence with your
application.

4a. Are you now employed?
Yes

No

(If "No," answer Item 4b also)

4c. Were you self-employed before
becoming totally disabled?
Yes

4b. When did you last work?
month day year
4d. What kind of work did you do?

No

(If "Yes," answer Item 4d and 4e also)

4e. Are you still self-employed?
Yes

4f. What kind of work do you do now?

No

(If "Yes," answer Item 4f also)

4g. Have you claimed or are you receiving
disability benefits from the Social
Security Administration (SSA)?
Yes

4h. Circle the highest year of education you
completed:
Grade school:
1
2
3
4

No
College:

1

5
9
2

6
10
3

7
11
4

8
12
over 4

4i. List the other training or experience you have and any certificates that you hold.

VA Form
JAN 2004

21-526

21-526, Part D

Page 1

SECTION Tell us
your work
II
history

5a. What was the name and
address of your employer?

SECTION
III

Tell us if
you are
in a
nursing
home

To get your claim
processed faster,
provide a
statement by an
official of the
nursing home that
tells us that you
are a patient in the
nursing home
because of a
physical or mental
disability and tells
us the daily charge
for your care.

In the table below, tell us about all of your employment, including
self-employment, for one year before you became disabled to the
present.
5b. What was 5c. When did your 5d. When did your 5e. How many
your job
work begin?
work end?
days were
title?
lost due to
disability?

5f. What were your
total annual
earnings?

mo day yr

mo day yr

$

mo day yr

mo day yr

$

mo day yr

mo day yr

$

In this section, tell us if you are in a nursing home. If you are in a nursing home, give us more
information about the nursing home.
6a. Are you now in a nursing home?
Yes

6b. What is the name and complete mailing
address of the facility or doctor?

No

(If "Yes," answer Item 6b also)

6c. Does Medicaid cover all or part of
your nursing home costs?
Yes

No

6d. Have you applied for Medicaid?
Yes

No

(If "No," answer Item 6d also)

SECTION Tell us the
net worth
IV

of you and
your
dependents

VA cannot pay you
pension if your net
worth is sizeable.

In this section, we ask you to give us specific information about your net worth and the net worth of
your dependents. You will need to enter this information in the tables on page 3.
You must include all assets in your net worth except those items you use everyday (See
definition of net worth below.)
You should subtract from the market value of your real estate any amounts that you owe
on it (such as mortgages, liens, etc.)
You can subtract mortgages on any property, and the value of the house or part of a
building that you live in as your primary residence.
You can report farms or buildings that you or a dependent own by reporting its value as "real
property."
Definitions:
Net worth is the market value of all interest and rights in any kind of property less any mortgages or
other claims against the property. However, net worth does not include the house you live in or a
reasonable area of land it sits on. Net worth also does not include the value of personal things you use
everyday like your vehicle, clothing, and furniture.
Go to Page 3 and fill out the table.
21-526, Part D

Page 2

SECTION
IV
(Continued)

Tell us about your net worth and your dependents' net worth.
For items 7a-h: provide the amounts.
If none, write "0" or "None"

Source

Veteran

Spouse

I. Name:

Child(ren)
II. Name:

III. Name:

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

7a. Cash, non-interest
bearing bank
accounts
7b. Interest bearing bank
accounts,certificates
of deposit (CDs)
7c. IRAs, Keogh Plans,
etc.
7d. Stocks and bonds

7e. Mutual funds

7f. Value of business
assets
7g. Real property (not
your home)
7h. All other property

SECTION Tell us
V
about the
income
you have
received
and you
expect to
receive

Payments from any
source will be
counted, unless the
law says that they
don't need to be
counted. VA will
determine any
amount that does not
count.

In this section, we ask you to give us specific information about the income you have received and
the income you expect to receive from all sources. You will need to enter this information in the
tables on Page 4. In these tables,
Report the total amounts before you take out deductions for taxes, insurance, etc.
Do not report the same information in both tables.
If you expect to receive a payment, but you don't know how much it will be, write
"Unknown" in the space.
If you do not receive any payments from one of the sources that we list, write "0" or
"None" in the space.
If you are receiving monthly benefits, give us a copy of your most recent award letter.
This will help us determine the amount of benefits you should be paid.
8. Will you receive any
income from rental
property or from
operation of a business
within 12 months of the
day you sign this form?
Yes

No

9. Will you receive
any income from
the operation of a
farm within 12
months of the day
you sign this form?
Yes

No

10. Do you expect to receive money
from a civilian agency,
corporation, or individual,
because of personal injury or
death within 12 months of the
day you sign this form?
Yes

No

21-526, Part D

Page 3

SECTION V (Continued)

Monthly Income - Tell us the income you and your dependents receive
every month.

For Items 11a-12f if none write "0" or "None"

Sources of recurring
monthly income

Veteran

Spouse

I. Name:

Child(ren)
II. Name:

III. Name:

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

11a. Social Security
11b. U.S. Civil Service
11c. U.S. Railroad
Retirement
11d. Military Retired
Pay
11e. Black Lung
Benefits
11f. Supplemental
Security (SSI)/
Public Assistance
11g. Other income
received monthly
(Please write in the
source below:)

Next 12 months - Tell us about other income for you and your dependents
Sources of income
for the next 12
months

Veteran

Spouse

12a. Gross wages and
salary
12b. Total interest and
dividends
12c. Worker's
compensation for
injury
12d. Unemployment
compensation
12e. Other military
benefit (Please
write in the source
below:)

I. Name:

Child(ren)
II. Name:

III. Name:

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

12f. Other one-time
benefit (Please
write in the
source below:)

SECTION VI
IMPORTANT - Items 13A
through 13E should be
completed only if you are
applying for
nonservice-connected
pension.

Your Name

Tell us any information concerning, Medical, Legal or Other Expenses - Family medical expenses actually paid by
you may be deductible from your income. Show the amount of unreimbursed medical expenses you paid for yourself or
relatives you are under an obligation to support. Also, show medical, legal or other expenses you paid because of a
disability for which civilian disability benefits have been awarded. When determining your income, we may be able to
deduct them from the disability benefits for the year in which the expenses are paid. Do not include any expenses for
which you were reimbursed. Show the Medicare deduction in line 1. If more space is needed attach a separate sheet.
13A. AMOUNT PAID
BY YOU

13B. DATE
PAID

13C. PURPOSE

(Doctor's fees, hospital
charges, Attorney fees, etc.)

13D. PAID TO

(Name of doctor, hospital,
pharmacy, Attorney, etc.)

13E. DISABILITY OR
RELATIONSHIP OF PERSON
FOR WHOM EXPENSES PAID

Your Social Security Number
21-526, Part D

Page 4

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

AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO THE
DEPARTMENT OF VETERANS AFFAIRS (VA)
Important Notice About Information Collection: 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

5. RELATIONSHIP OF CLAIMANT TO VETERAN

6. CLAIMANT'S SOCIAL SECURITY NUMBER

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 ON PAGE 2 AND CHECK THE APPROPRIATE BLOCK IN
ITEM 9C.
VA FORM
MAY 2004

21-4142

EXISTING STOCKS OF VA FORM 21-4142, SEP 2003,
WILL BE USED.

SECTION III - CONSENT TO RELEASE INFORMATION

READ ALL 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 provided 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 by the HIPAA 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 you 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

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