Form 21-0304 Application for Benefits for Certain Children with Disab

OMB Approved 2900-0572
Respondent Burden: 10 minutes

APPLICATION FOR BENEFITS FOR CERTAIN
CHILDREN WITH DISABILITIES BORN OF
VIETNAM AND CERTAIN KOREA SERVICE VETERANS
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 5, Code of Federal Regulations 1.526 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 Compensation, Pension,
Education, and Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your
SSN account information is mandatory. Applicants are required to provide their SSN 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 Federal Statute of law in effect prior to January 1, 1975, and still in effect.
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.
Respondent Burden: We need this information to determine eligibility for benefits for children with certain disabilities who are born of Vietnam veterans and certain
Korea Service veterans (38 U.S.C. chapter 18). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 10
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.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send
comments or suggestions about this form.
NOTE - After completing the form mail to: VA Regional Office, Veterans Service Center (339/21), Box 25126, Denver, CO 80225
1. NAME OF CLAIMANT - CHILD (First, middle, last)

2. SOCIAL SECURITY NUMBER OF CLAIMANT - CHILD (If available)

3. CLAIMANT - CHILD’S DATE OF BIRTH (Mo., day, yr.)

4. CLAIMANT - CHILD’S PLACE OF BIRTH (City and State)

5. ADDRESS OF CLAIMANT - CHILD (Include number and street or rural route, city or P.O., State and ZIP Code)

6. TELEPHONE NUMBER OF CLAIMANT - CHILD (Include Area Code)

(

)
7. NAME(S) OF NATURAL PARENT(S) (Please provide information for both)

A. FATHER (First, middle, last)

B. MOTHER (First, middle, last)

8. ADDRESS, TELEPHONE NUMBER AND VETERAN STATUS OF NATURAL PARENT(S)
A. FATHER (Include number and street or rural route, city or P.O., State and
ZIP Code)

B. MOTHER (Include number and street or rural route, city or P.O., State and
ZIP Code)

C. VIETNAM SERVICE?

D. VIETNAM SERVICE?

(If "Yes,"provide dates in 8E)
YES
NO
E. PLEASE PROVIDE THE DATES THAT CHILD’S FATHER WAS IN VIETNAM
FROM

(If "Yes,"provide dates in 8F)
YES
NO
F. PLEASE PROVIDE THE DATES THAT CHILD’S MOTHER WAS IN VIETNAM

TO

FROM

TO

9. SOCIAL SECURITY NUMBER(S) OF NATURAL PARENT(S)
A. FATHER

B. MOTHER

10. VA CLAIM NUMBER(S) OF NATURAL PARENT(S) (If veteran previously applied to VA for any benefit)
A. FATHER

VA FORM
SEP 2006

B. MOTHER

21-0304

SUPERSEDES VA FORM 21-0304, MAR 2004,
WHICH WILL NOT BE USED.

(Continue on Reverse)

11. IF CHILD IS UNDER AGE 18 WHO HAS CUSTODY, IF OTHER THAN NATURAL PARENT? (Complete Items 11A, 11B & 11C)
A. NAME OF CUSTODIAN/GUARDIAN OF
CLAIMANT-CHILD

B. RELATIONSHIP TO CHILD
ADOPTIVE PARENT

C. ADDRESS OF CUSTODIAN/GUARDIAN OF CLAIMANT-CHILD
GUARDIAN

OTHER (Specify)
12A. IF CLAIMANT-CHILD IS AGE 18 OR OLDER HAS THE CLAIMANT-CHILD BEEN DECLARED INCOMPETENT?
YES
NO (If "Yes," complete Items 12B and 12C)
12B. NAME AND ADDRESS OF THE COURT WHICH MADE THE FINDING OF INCOMPETENCY? 12C. NAME AND ADDRESS OF GUARDIAN

13. DISABILITIES CLAIMED

14. NAME AND ADDRESS OF PRIMARY HEALTH CARE PROVIDER FOR THE CLAIMANT

15A. NAME AND PLACE FIRST DIAGNOSED

15B. DATE FIRST DIAGNOSED

16A. NAME(S) AND PLACE(S) OF MOST RECENT TREATMENT

16B. DATE(S) OF TREATMENT

DIRECT DEPOSIT INFORMATION
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 17A, 17B and 17C 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 17A. 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 us a brief description of why you do
not wish to participate in Direct Deposit.
17A. ACCOUNT NUMBER (Please check the appropriate box and provide that account number, if applicable)
CHECKING
SAVINGS (Please provide account number
17B. NAME OF FINANCIAL INSTITUTION

)

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A
FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT

17C. ROUTING OR TRANSIT NUMBER

I/We, the undersigned, hereby authorize the hospital or physician shown in Items 14, 15A and 16A to disclose and release to the Department of
Veterans Affairs any information that may have been obtained in connection with the physical examination or treatment of the child.
18A. SIGNATURE(S) OF PARENT/GUARDIAN/ADULT CHILD

18B. DATE SIGNED

19A. SIGNATURE OF WITNESS (Required)

19B. DATE SIGNED

I/We, the undersigned, declare under penalty of perjury that the information provided is true and correct and that the child named in Item 1 is the natural
child of the person(s) named in Item 7.
20A. SIGNATURE OF CHILD (IF AN ADULT) OR PARENT OR GUARDIAN

20B. DATE SIGNED

21A. SIGNATURE OF VIETNAM VETERAN PARENT (IF AVAILABLE OR DIFFERENT)

21B. DATE SIGNED

APPLICATION INFORMATION AND INSTRUCTIONS FOR VA FORM 21-0304
IMPORTANT - Please read information and instructions before completing attached application.

Children of Women Vietnam Veterans Born with Certain Birth Defects - 38 U.S.C. 1815
This section of the law authorizes the payment of monetary benefits to, or on behalf of, certain children of
female veterans who served in Vietnam. Benefits are payable to qualifying children, or on their behalf,
beginning December 1, 2001. There are three eligibility requirements. To be eligible, the child must:

. be the biological child of a woman veteran who served in the Republic of Vietnam (RVN),
been conceived after the date the veteran first served in the RVN during the
. have
period 2/28/61 to 5/7/75, and
have certain birth defects identified by the Secretary of Veterans Affairs as resulting in
physical or mental disability
. permanent
The law does not include conditions that are:

. a familial disorder
. a birth-related injury, or
. a fetal or neonatal infirmity with well-established causes.
Completion of VA Form 21-0304, Application For Benefits For Certain Children With Disabilities Born of
Vietnam and Certain Korea Service Veterans, is required.
The effective date is December 1, 2001.

Spina Bifida Benefits Eligibility -- 38 U.S.C. 1805
Monetary benefits may be paid to, or on behalf of, certain children of veterans who served in the Republic
of Vietnam or the demilitarized zone in Korea during the Vietnam era. Benefits are payable to qualifying
children regardless of age or marital status. To be eligible, the child must:
the biological child of a veteran who served in the Republic of Vietnam (RVN), or a
. beveteran
who served in or near the demilitarized zone (DMZ) in Korea and was exposed to
herbicides, and
been conceived after the date the veteran first served in the RVN during the period
. have
1/9/62 and 5/7/75, or after the date the veteran first served in or near the DMZ in Korea
during the period 9/1/67 to 8/31/71, and

. have
any type of spina bifida other than spina bifida occulta. The diagnosis may be
established by private physicians, or government or private institution examination reports.
Possible Entitlement: The law does not allow payment of both benefits at the same time. If entitlement
exists under both laws, benefits will be paid under 38 U.S.C. 1815.

Health Coverage: The law allows health care covering the defects or any disability associated with the
birth defects. This care may be provided directly or by contract.

Vocational Rehabilitation: If achievement of a vocational goal is reasonably feasible, a program of
vocational training provided by VA’s Vocational Rehabilitation and Employment Service is available to an
eligible child.

Monetary Allowance: The law includes levels of monetary allowance, each based on the level of
disability of the eligible child.

Mail The Completed Form To:

VA Regional Office
Veterans Service Center (339/21)
Box 25126
Denver, CO 80225

VA FORM
SEP 2006

21-0304