Form FL 29-30A FL 29-30A Supplemental Disability Report

DEPARTMENT OF VETERANS AFFAIRS
Regional Office and Insurance Center

.

In Reply Refer To:
Name of Veteran

File Number:

The information requested below is needed in connection with your claim for disability
insurance benefits.
OMB Approved No. 2900-0129
Respondent Burden: 5 Mins.

SUPPLEMENTAL DISABILITY REPORT
PRIVACY ACT INFORMATION - No claim for disability benefits may be approved until proof of entitlement is received (38 U.S.C.
1912,1915, 1942 and 1948). The information provided on a voluntary basis will be used by VA employees and your authorized reprentatives
in the maintenance of Government insurance programs. The responses which are furnished may be disclosed outside VA only if the
disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 36VA00, Veterans and
Armen Forces Personnel U.S. Government Life Insurance Records - VA, published in the Federal Register.
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 burden for this collection of information is estimated to average 5 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.
1.ARE YOU WORKING NOW?
YES

NO

2. HAVE YOU WORKED
SINCE_______________________________?

YES

NO

3. DATE EMPLOYMENT STARTED______________________________NUMBER OF HOURS WORKED PER

4. NAME AND ADDRESS OF EMPLOYER

5. WHERE HAVE YOU RECEIVED MEDICAL TREATMENT SINCE______________________________?
a. Name and address of physician
or hospital
b. Dates of treatment

6. DAYTIME TELEPHONE NUMBER

7. SOCIAL SECURITY NUMBER

8. SIGNATURE OF INSURED VETERAN OR FIDUCIARY

EXISTING STOCKS OF VA FORM 29-30a, SEP 1992,
WILL BE USED.

9. DATE SIGNED

FL 29-30a
OCT 2004(R)