Form VA Form 21-526c VA Form 21-526c Pre-Discharge Compensation Claim

OMB Control No. 2900-0743
Respondent Burden: 15 minutes
Expiration Date: XXXXXXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

PRE-DISCHARGE COMPENSATION CLAIM

(For use only with Benefits Delivery at Discharge (BDD) or Quick Start Claims)
IMPORTANT: Please read the Privacy Act and Respondent Burden on the back before completing the form.
THIS FORM WILL BE USED FOR (CHECK ONLY ONE)
Benefits Delivery at Discharge (BDD) CLAIMS

Quick Start Claims

SECTION I: TO BE COMPLETED BY SERVICE MEMBER

1. SERVICE MEMBER NAME (Last, first, middle)

2. PLACE OF SEPARATION

4. DATE OF BIRTH (MM,DD,YYYY)

3. SOCIAL SECURITY NUMBER

5. SEX

MALE
FEMALE
6B. TELEPHONE NUMBERS (Include Area Code)

6A. CURRENT ADDRESS

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

Apt. number

City
State
7A. WORK E-MAIL ADDRESS (If applicable)

Evening

Cell phone
Country
7B. PERSONAL E-MAIL ADDRESS (If applicable)

ZIP Code

8A. FORWARDING ADDRESS

8B. TELEPHONE NUMBER

9A. NAME AND RELATIONSHIP OF NEXT
OF KIN

9B. ADDRESS OF NEXT OF KIN

9C. TELEPHONE NUMBER
OF NEXT OF KIN

10A. HAVE YOU EVER FILED A CLAIM WITH VA?
(If "Yes," provide your file number in Item 10B)
YES
NO

10B. VA FILE NUMBER

11. WHAT DISABILITIES ARE YOU CLAIMING? SUBMIT ADDITIONAL SUPPORTING STATEMENTS AND INFORMATION CONCERNING YOUR
CLAIMED DISABILITIES ON VA FORM 21-4138, STATEMENT IN SUPPORT OF CLAIM, AVAILABLE AT www.va.gov/vaforms

IMPORTANT: If claiming dependents, please attach a completed VA Form 21-686c, Declaration of Status of Dependents,
available at www.va.gov/vaforms
SECTION II: SERVICE INFORMATION
12A. DID YOU SERVE UNDER ANOTHER NAME?
YES (If "Yes," go to Item 12B)
NO

12B. PLEASE LIST OTHER NAME(S) YOU SERVED UNDER

(If "No," go to Item 13A)

13A. I ENTERED THIS CURRENT PERIOD OF
ACTIVE SERVICE ON (MM,DD,YYYY)
mo

day

13B. BRANCH OF SERVICE

13C. ANTICIPATED DATE
OF RELEASE FROM
ACTIVE DUTY

NO

14B. DATE OF ACTIVATION (MM,DD,YYYY)

(If "Yes," provide date of activation in Item 14B)

mo

15A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?

16A. DO YOU HAVE ADDITIONAL PERIODS OF ACTIVE SERVICE?
YES (If "Yes," go to Item 16B)
NO
VA FORM
XXX 2014

day

yr

15B. WHAT IS THE TELEPHONE
NUMBER OF YOUR CURRENT
UNIT? (Include Area Code)

16B. I PREVIOUSLY ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
mo

(If "No," go to Item 17A)

21-526c

NO

YES

yr

14A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
AUTHORITY OF TITLE 10, U.S.C.?
YES

13D. DID YOU SERVE IN A
COMBAT ZONE SINCE
9-11-2001?

SUPERSEDES VA FORM 21-526c, JAN 2014,
WHICH WILL NOT BE USED.

day

yr
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SECTION III: MILITARY RETIRED PAY

17A. WILL YOU RECEIVE RETIRED PAY?
YES

NO

(If "Yes," complete Item 17B)

18A. WILL YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE PAY?
YES

NO

17B. TYPE OF RETIRED PAY?
LONGEVITY
DISABILITY
TDRL

18B. LIST AMOUNT (If known)

18C. LIST TYPE (If known)

(If "Yes," complete Items 18B and 18C)

IMPORTANT: Unless you check the box in Item 19 below, you are telling us that you are choosing to receive VA compensation
instead of military retired pay, if it is determined you are entitled to both benefits. If you are awarded military retired pay prior to
compensation, we will reduce your retired pay by that amount. VA will notify the Military Retired Pay Center of all benefit changes.
If you receive both military retired pay and VA compensation, some of the amount you get may be recouped by VA, or, in the case of
Voluntary Separation Incentive (VSI), by the Department of Defense.
19.

No, I do not want VA compensation in lieu of military retired pay.
SECTION IV: DIRECT DEPOSIT INFORMATION

The Department of Treasury requires all Federal benefit payments 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 20, 21 and 22 to enroll in direct deposit. If you do
not have a bank account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard
you must apply at www.usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to enroll, you must contact representatives handling
waiver requests for the Department of Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any questions or
concerns you may have.
20. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)
CHECKING

SAVINGS

21. NAME OF FINANCIAL INSTITUTION (Please provide the name of
the bank where you want your direct deposit)

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT
WITH A FINANCIAL INSTITUTION OR CERTIFIED
PAYMENT AGENT
22. ROUTING OR TRANSIT NUMBER (The first nine numbers located
at the bottom left of your check)

SECTION V: CERTIFICATIONS AND SIGNATURE

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, and I waive any privilege which makes the information confidential.
23A. YOUR SIGNATURE (Do NOT print)

23B. DATE SIGNED

SECTION VI: WITNESSES TO SIGNATURE
24A. SIGNATURE OF WITNESS (If claimant signed above using an "X")
24B. PRINTED NAME AND ADDRESS OF WITNESS

25A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

25B. PRINTED NAME AND ADDRESS OF WITNESS

PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (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, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. 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. Social Security information: You are required to provide the
Social Security number 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 purposes stated above.
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 15 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
VA FORM 21-526c, XXX 2014

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