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

INFORMATION AND INSTRUCTIONS FOR COMPLETING THE
VETERAN'S APPLICATION FOR COMPENSATION AND/OR PENSION
IMPORTANT - Please read the information below carefully to help you complete this form more quickly and
accurately. Some parts of the form also contain notes or specific instructions for completing that part.
Frequently Asked Questions
What do I use VA Form 21-526 for?
Use VA Form 21-526 to apply for compensation and/or pension benefits.
Should I apply for compensation or pension benefits?
You should apply for compensation benefits if:
You currently have a disability that is the result of an injury, disease,
or an event in military service.
You should apply for pension benefits if all of the following are true:
You are age 65 or older or are permanently and totally disabled. Your disabilities do not have
to be related to your military service.
You served on active duty with at least one day during a period of war. Visit the VA pension
benefits web site at http://www.benefits.va.gov/pension/vetpen.asp for more specific information.
Your income and assets do not exceed certain limits. Visit the VA pension rates web site
at http://www.benefits.va.gov/pension/rates.asp for the maximum yearly income VA allows.
Note: Read the "Important" statement below and attach current medical evidence showing that you are
permanently and totally disabled if necessary.
IMPORTANT: If you are a veteran who is claiming pension and you are 65 or older, or determined to be disabled by the
Social Security Administration, you DO NOT have to submit medical evidence with your application unless you are
claiming special monthly pension. Special monthly pension is an increased amount paid to individuals who, due to mental
or physical disability, require the aid of another person to perform activities of daily living, are a patient in a nursing
home, have severe visual problems, or are substantially confined to his or her home.
May I apply electronically?
You can apply for VA disability compensation and pension online through eBenefits at www.ebenefits.va.gov. For
disability compensation claims, you can also upload all supporting evidence you may have and make your claim a Fully
Developed Claim. To file a claim for VA disability compensation electronically, go to eBenefits, select Apply for Benefits
and then select Apply for Disability Compensation. You will need to create an eBenefits account to apply for disability
compensation online. To file a claim for VA pension electronically, go to eBenefits, select Apply for Benefits, and then
select Apply for Veterans Benefits via VONAPP. Once you submit your claim, you can track the status using eBenefits.
NOTE: You can contact an accredited Veterans Service Officer to assist you with your application.
What parts of the form should I complete?
You should complete only the parts related to the benefit for which you are applying:
If you are applying for compensation ONLY, skip parts VII, VIII, IX, X.
If you are applying for pension, complete the ENTIRE form.
If you need more space to answer a question or have a comment about a specific item on this
form, please place it in Part XII, Item 46, "Remarks." Please identify your answer or
comment by the part and item number.
VA FORM
XXX 20XX

21-526

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

PAGE 1

Where can I get help?
You can ask VA to help you fill out the form by contacting a regional office or call center. Before you contact us, make
sure you gather the necessary materials and complete as much of the form as you can. You can contact VA in the
following ways:
By internet: https://iris.va.gov
In person: You can locate the address of the closest regional office at
http://www.va.gov/directory or 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
Relay Number 711 (Hearing Impaired TDD line)
1-412-395-6272 (If living outside the U.S.)
You can also contact a VA-accredited veterans service organization (VSO) representative to help you with your claim.
If you want to use a representative to help you, consult your local telephone book to contact a particular VSO or
contact the closest VA office. You may also seek the assistance of a VA-accredited attorney or claims agent.
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 should I do when I have finished my application?
You should provide your signature in Part XI, Item 43A. Be sure to sign every form you fill out
before you send it to us. If you don't sign the form, VA will return it for you to sign, and it will
take longer for us to process.
Attach any materials that support and explain your claim.
Mail or take your application to the closest VA regional office. VA regional office addresses are
available on the internet at http://www.va.gov/directory
Do I need to keep a copy of my application?
It is important that you keep a copy of all completed forms and materials you give to VA.
Social Security Disability and Supplemental Security Income Benefits
Social Security Disability and Supplemental Security Income are two Federal programs that help people with disabilities.
While these programs are different in many ways, the Social Security Administration (SSA) administers both programs. If
you think you have a disabling condition, you may qualify for benefits under one or both of these programs and should
contact Social Security.
How can I contact SSA if I have questions?
You can find answers to most questions and file a claim online at www.socialsecurity.gov. Specific information is
available for active duty military, veterans, and their families at www.socialsecurity.gov/woundedwarriors.
You can also contact SSA in the following ways:
By phone: (Monday-Friday, 7 a.m. - 7 p.m. EST) at one of the following toll-free numbers:
1-800-772-1213
Relay Number 711 (TDD if you are deaf or hard of hearing)
By mail or in person: You can locate the address of the Social Security office nearest to you in your
telephone book blue pages under "United States Government, Social Security Administration".
PAGE 2

SPECIFIC INSTRUCTIONS FOR VA FORM 21-526
Part II - Nature and History of Service-Related Disability(ies)
What disabilities should I list?
List the disease(s) or medical condition(s) that form the basis of your claim for service connected compensation. Be as
specific as you can. Indicate the approximate date the disability began and the place of treatment.
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 form. VA will help you obtain records 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 by them, and the condition
for which you were treated. If you received treatment from a non VA health care provider complete and return
VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA) and VA Form
21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), in order for VA
to obtain your treatment records. Additional VA Forms 21-4142a can be obtained from the VA forms web site at
www.va.gov/vaforms.
Part III - Active Duty Service Information
Do I need to include my active duty service information?
Please provide the information for each period of active duty (provide a copy of your DD214 or other separation
papers for all periods of active duty service).
Part IV - Reserve and National Guard Service Information
What If I have Reserve or National Guard Service?
This section tells us if you were a member of the Reserve or National Guard. Complete information for each period of
Reserve and National Guard service. Provide a copy of your DD214 or other separation papers for all periods of active
service.
Part V - Military Retired/Severance Pay
What If I have received or will receive military pay?
This section asks about your military severance or separation pay, the type, and the amount. If you currently receive
military retired pay, we may reduce your retired pay by the amount of any compensation that we award. It is to your
advantage because VA compensation is not taxable while retired pay is taxable. However, if you wish to receive military
retired pay rather than VA compensation, you must check the box in Item 25. Some veterans receive various readjustment,
separation, or severance pay from service departments which may be recouped in full or in part from VA benefit
payments.
Part VI - Marital and Dependency Information
Who can I count as a dependent spouse?
A spouse is a person who is married to the veteran (authority: 38 U.S.C. subsection 101(31)). If you are certifying that you
are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse
resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when
you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognizes marriages is
available at http://www.va.gov/opa/marriage/.
Note: It is important that you provide your marital history and that of your spouse.
Who can be recognized as a dependent child?
VA recognizes the veteran's biological child, adopted child, and stepchild. However, the child must be unmarried and:
under the age of 18, or
at least 18 but under 23 and pursuing an approved course of education, or
permanently incapable of self support before reaching the age of 18.
PAGE 3

SPECIFIC INSTRUCTIONS FOR VA FORM 21-526 (Continued)
Part VII - Veterans Pension
This section asks you to provide information about the disabilities that prevent you from working. We also ask you to tell
us if you require the regular assistance of another person, if you are housebound, if you are in a nursing home, if you are
in receipt of Social Security Disability or Supplemental Security Income, or if you have applied for Medicaid.
Part VIII - Income and Asset Information
This section asks you to provide specific information about the Social Security benefits you and your dependants receive.
Report the gross amount you and your dependents receive monthly before deductions are taken out. If you have a copy of
your most recent Social Security award letter, please include a copy of the letter with your application.
This section also asks you to tell us if you or your dependents receive or received income from sources other than Social
Security. VA also needs to know if you or your dependents own your primary residence and we ask you other questions
about the value of your assets and your dependents' assets. Your assets do include your spouse's assets. Although your
assets do not include your child's assets, you must tell us if your child has significant assets. Your assets include all the
money and the fair market value of any property you and your spouse own. Assets do not include your primary residence
or personal effects such as appliances and vehicles you or your dependents need for transportation.
This section also asks if you have transferred assets in the past three calendar years.
IMPORTANT: If you receive or received income in addition to Social Security benefits or you have significant assets or
have transferred assets, we will require you to complete VA Form 21P-0969, Income and Asset Statement, in addition to
this application.
Part IX - Information about Your Unreimbursed Medical or Other Expenses
When determining your eligibility for pension, we may be able to deduct unreimbursed medical expenses from your
income for the year in which the expenses are paid. Report the amount of unreimbursed medical expenses, including the
Medicare deductions you paid (out-of-pocket) for yourself or relatives you are under an obligation to support. Do not
report any expenses you did not pay or expenses for which you were or will be reimbursed.

PRIVACY ACT INFORMATION: 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 Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary; however, no allowance of compensation or
pension may be granted unless this form is completed fully as required by law. Giving us you and your dependents' Social Security numbers 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. Information submitted is subject to verification through computer matching programs with other Federal or state
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 your eligibility for compensation and/or pension (38 U.S.C. 5101). Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour 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.

PAGE 4

OMB Control No. 2900-0001
Respondent Burden: 1 hour
Expiration Date: XX/XX/XXXX

VETERAN'S APPLICATION FOR COMPENSATION AND/OR PENSION
IMPORTANT - Read information and instructions carefully before completing the form. Type, print, or write plainly.

(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

PART I - VETERAN'S INFORMATION
1. FOR WHAT BENEFIT ARE YOU APPLYING?
COMPENSATION

PENSION

BOTH COMPENSATION AND PENSION

2. HAVE YOU PREVIOUSLY APPLIED FOR ANY VA BENEFIT(S)? (Check applicable box)
PENSION

OTHER (Specify)

COMPENSATION

3. FIRST, MIDDLE, LAST NAME OF VETERAN
4A. VETERAN'S SOCIAL SECURITY NO.

4B. VA FILE NUMBER (If applicable)

4C. SPOUSE'S SOCIAL SECURITY NO.

4D. IF YOU SERVED UNDER ANOTHER NAME, GIVE NAME AND PERIOD DURING WHICH YOU SERVED AND SERVICE NO.
5. MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
7. E-MAIL ADDRESS (If applicable)

6. TELEPHONE NUMBER(S) (Include Area Code)
B. EVENING

A. DAYTIME

C. CELL
9. SEX

8B. PLACE OF BIRTH

8A. DATE OF BIRTH (Month, day, year)

MALE
10B. WHEN WAS THE CLAIM FILED?
(Mo., day, yr.)

10A. HAVE YOU EVER FILED A CLAIM FOR COMPENSATION FROM
THE OFFICE OF WORKERS' COMPENSATION PROGRAMS?
(Formerly the U.S. Bureau of Employees Compensation)
YES

NO

FEMALE

10C. FOR WHAT DISABILITY ARE YOU
RECEIVING BENEFITS?

(If "Yes," complete Items 10B & 10C)

PART II - NATURE AND HISTORY OF SERVICE-RELATED DISABILITY(IES) (If you need more space please use Item 46, "Remarks")
11. PLEASE PROVIDE NATURE OF SICKNESS, DISEASE, OR INJURIES FOR WHICH THIS CLAIM IS MADE; DATE EACH BEGAN; AND PLACE OF TREATMENT

A. LIST DISABILITY(IES)

B. DATE BEGAN

12A. ARE YOU NOW OR HAVE YOU RECEIVED
TREATMENT OR DOMICILIARY CARE AT A VA
MEDICAL FACILITY?
YES

12B. DATES OF TREATMENT/CARE
Month

NO

13C. DATES OF CONFINEMENT
FROM

(If "Yes," complete Items 13B and 13C)

NO

NO

TO

15. ARE YOU CLAIMING A DISABILITY RELATED TO ASBESTOS
EXPOSURE? (If "Yes," list disability(ies) below)
YES

16. ARE YOU CLAIMING A DISABILITY RELATED TO MUSTARD GAS EXPOSURE?
(If "Yes," list disability(ies) below)
YES

12C. NAME AND ADDRESS OF VA MEDICAL FACILITY
(If you need more space use Item 46, "Remarks")

Year

13B. NAME OF COUNTRY

14. ARE YOU CLAIMING A DISABILITY RELATED TO AGENT ORANGE OR
OTHER HERBICIDE EXPOSURE? (If "Yes," list disability(ies) below)
YES

Day

NO (If "Yes,"complete Items 12B &12C)

13A. HAVE YOU EVER BEEN A PRISONER OF WAR?
YES

C. PLACE OF TREATMENT

NO

17. ARE YOU CLAIMING A DISABILITY RELATED TO IONIZING RADIATION
EXPOSURE? (If 'Yes," list disability(ies) below)
YES

NO

18. ARE YOU CLAIMING A DISABILITY RELATED TO AN ENVIRONMENTAL HAZARD EXPOSURE DURING THE GULF WAR? (If "Yes," list disability(ies) below)
YES

NO

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 43A THRU 43C ON PAGE 10.
VA FORM
XXX 20XX

21-526

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

PAGE 5

PART III - ACTIVE DUTY SERVICE INFORMATION
NOTE: Please complete the information for each period of active duty. Attach DD214 or other separation papers for all periods of active duty. If you do not have
your DD214 form or other separation papers, check the box.
19A. ENTERED INTO SERVICE
DATE

19C. SEPARATED FROM SERVICE

19B. SERVICE
NUMBER

PLACE

DATE

19D. BRANCH OF
SERVICE

PLACE

19E. GRADE, RANK OR
RATING, ORGANIZATION

PART IV - RESERVE AND NATIONAL GUARD SERVICE INFORMATION
NOTE: Enter complete information for each period of Reserves and National Guard service. Attach any separation papers you have.
20A. ENTERED INTO SERVICE
DATE

PLACE

20D. SERVICE
STATUS (Reserve,
National Guard)

20C. SEPARATED FROM SERVICE

20B. SERVICE
NUMBER

DATE

PLACE

22A. ARE YOU NOW A MEMBER OF THE RESERVES
OR NATIONAL GUARD? IF SO, GIVE THE BRANCH
OF SERVICE

21. IF DISABILITY OCCURRED DURING ACTIVE OR INACTIVE
DUTY FOR TRAINING, GIVE BRANCH OF SERVICE AND DATE
OF OCCURRENCE

YES

NO

20E. GRADE, RANK OR
RATING, ORGANIZATION

22B. RESERVE STATUS
ACTIVE

RESERVE
OBLIGATION

INACTIVE

BRANCH

22C. NAME, ADDRESS AND PHONE NO. OF RESERVE OR NATIONAL GUARD UNIT (If additional space is needed, use Item 46 "Remarks")

PART V - MILITARY RETIRED/SEVERANCE PAY
IMPORTANT - Unless you check the box in Item 25 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 the amount of any
compensation that you are awarded. 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 receive may be recouped by VA, or, in the case of Voluntary Separation Incentive (VSI), by the Department of Defense.
23A. ARE YOU RECEIVING MILITARY
RETIRED PAY? (If "Yes," complete

23B. WILL YOU RECEIVE MILITARY RETIRED PAY IN THE
FUTURE? (If "Yes," explain, i.e. Future Reserve/National Guard

Items 23C & 23D)
YES

23D. MONTHLY
AMOUNT

Retirement, Pending MEB/PEB)

NO

YES

NO

$

24. RETIRED STATUS

25. NO, I DO NOT WANT VA COMPENSATION IN LIEU OF MILITARY RETIRED PAY
TEMPORARY DISABILITY
RETIRED LIST

RETIRED

23C. BRANCH OF
SERVICE

(Check box, if applicable)

DISABLED
RETIRED LIST

26. HAVE YOU EVER APPLIED FOR OR RECEIVED DISABILITY SEVERANCE/SEPARATION PAY, OR ANY OTHER LUMP SUM PAYMENT FROM THE ARMED
FORCES? (If "Yes," list type, amount, date it was received, and the branch of service below)
YES

NO

PART VI - MARITAL AND DEPENDENCY INFORMATION
27B. SPOUSES'S BIRTHDATE (Mo., day, yr.)

27A. MARITAL STATUS (If married, complete Items 27B thru 29D)
MARRIED

WIDOWED

27C. NUMBER OF TIMES
YOU HAVE BEEN
MARRIED (To include
current marriage)

DIVORCED

27D. NUMBER OF TIMES YOUR
PRESENT SPOUSE HAS
BEEN MARRIED (To

NO

YES

NO

(If "Yes,"complete
Item 27F)

C-

27H. REASON FOR SEPARATION (For example,
marital problems, job requirements, health, etc.)

27I. PRESENT ADDRESS OF SPOUSE

(If "No,"complete Items 27H thru 27J)

27J. AMOUNT YOU CONTRIBUTE TO YOUR
SPOUSE'S MONTHLY SUPPORT

$

27F. SPOUSE'S VA FILE NUMBER (If any)

27E. IS YOUR SPOUSE ALSO A VETERAN?

include current marriage)

27G. DO YOU LIVE TOGETHER?
YES

NEVER MARRIED (If never married, skip to Item 30)

27K. HOW WERE YOU MARRIED?
CLERGYMAN OR AUTHORIZED
PUBLIC OFFICIAL

TRIBAL

COMMON-LAW

PROXY

OTHER (Explain)

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 43A THRU 43C ON PAGE 10.
PAGE 6

PART VI - MARITAL AND DEPENDENCY INFORMATION - CONTINUED (If you need additional space, use Item 46 "Remarks")
FURNISH THE FOLLOWING INFORMATION ABOUT EACH OF YOUR MARRIAGES (IF NOT APPLICABLE, WRITE "N/A")
28A. DATE AND PLACE OF MARRIAGE
MONTH, YEAR

28C. TERMINATED

28B. TO WHOM MARRIED

(Death, Divorce)

CITY, STATE

28D. DATE AND PLACE TERMINATED
MONTH, YEAR

CITY, STATE

FURNISH THE FOLLOWING INFORMATION ABOUT EACH PREVIOUS MARRIAGE OF YOUR PRESENT SPOUSE (IF NOT APPLICABLE, WRITE "N/A")
29A. DATE AND PLACE OF MARRIAGE
MONTH, YEAR

29C. TERMINATED

29B. TO WHOM MARRIED

(Death, Divorce)

CITY, STATE

29D. DATE AND PLACE TERMINATED
MONTH, YEAR

CITY, STATE

DEPENDENCY - Dependent Children Information (If you need additional space, use Item 46 "Remarks")
FURNISH THE FOLLOWING INFORMATION FOR EACH OF YOUR DEPENDENT CHILDREN
30A. NAME OF CHILD

(First, middle initial, last)

30B. DATE & PLACE
OF BIRTH

(City, state or country)

30D. CHECK EACH APPLICABLE CATEGORY
30C. SOCIAL SECURITY
18-23 YRS.
CHILD
SERIOUSLY
NUMBER
BIOLOGICAL ADOPTED STEPCHILD OLD AND IN
PREVIOUSLY
DISABLED
SCHOOL
BEFORE AGE 18 MARRIED

(Month, day, year)
Place:

(Month, day, year)
Place:

(Month, day, year)
Place:

FURNISH THE FOLLOWING INFORMATION FOR EACH OF YOUR DEPENDENT CHILDREN WHO DO NOT LIVE WITH YOU
31A. NAME(S) OF ANY CHILD(REN) NOT
IN YOUR CUSTODY

31B. NAME AND ADDRESS OF
PERSON HAVING CUSTODY

31C. MONTHLY AMOUNT YOU
CONTRIBUTE TO
CHILD'S SUPPORT

$
$
PART VII - VETERANS PENSION (If you need additional space use Item 46 "Remarks")
NOTE: If you are a veteran who is claiming pension and you are age 65 or older, or determined disabled by the Social Security Administration, you DO NOT have
to submit medical evidence with your application unless you are claiming special monthly pension.
32. WHAT DISABILITIES PREVENT YOU FROM WORKING? (List below)

33. ARE YOU CLAIMING SPECIAL MONTHLY PENSION BECAUSE YOU NEED THE
REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL PROBLEMS,
OR ARE GENERALLY CONFINED TO YOUR HOME?
(If "YES," complete and attach with this application VA Form 21-2680
YES
Examination for Housebound Status or Permanent Need for Regular Aid and
Attendance. Please ensure that each item on the form is complete and that it is
NO
signed by a physician, physician assistant (PA), certified nurse practitioner
(CNP), or clinical nurse specialist (CNA))

NURSING HOME INFORMATION

NOTE: If you are in a nursing home, please submit a statement from an official of the nursing home that tells VA that you are a patient in the nursing home due to
a physical or mental disability. The statement should include the monthly charge you are paying out-of-pocket for your care.
34A. ARE YOU NOW IN A NURSING HOME?
YES

NO

34B. NAME AND COMPLETE MAILING ADDRESS OF THE FACILITY

(If "YES,"complete
Items 34B thru 34D)

34D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME COSTS OR HAVE YOU APPLIED AND NOT RECEIVED
A DECISION?
YES

NO

APPLIED - NOT RECEIVED DECISION

34C. HAVE YOU APPLIED FOR
MEDICAID?
YES

NO

34E. ARE YOU RECEIVING SOCIAL SECURITY DISABILITY (SSD) OR SUPPLEMENTAL
SOCIAL SECURITY INCOME (SSI) OR HAVE YOU APPLIED FOR SSD OR SSI BUT NO
DECISION HAS BEEN MADE:
YES

NO

APPLIED - NOT RECEIVED DECISION

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 43A THRU 43C ON PAGE 10.
PAGE 7

PART VIII - INCOME AND ASSET INFORMATION (If you need more space, attach a separate sheet)
35. DO YOU OR YOUR DEPENDENTS RECEIVE SOCIAL SECURITY BENEFITS?
YES

NO

(If "NO," skip to Item 36)

(If "YES," complete Items 35A and 35B)
B. GROSS MONTHLY AMOUNT

A. SOCIAL SECURITY RECIPIENT

$
$

$
$
$

$
$

$

$

$

$
36. DO YOU OR YOUR DEPENDENTS OWN YOUR/YOUR FAMILY'S PRIMARY RESIDENCE?
YES

NO

(If "NO," skip to Item 38A after reading the "Important Information" below) (If "YES," complete Items 37A and 37B)

37A. WHAT IS THE SIZE OF THE LOT ON WHICH THE
PRIMARY RESIDENCE SITS?
_________________ Square Feet

37B. COULD ANY PART OF THE LOT BE SOLD WITHOUT SELLING THE RESIDENCE?
YES

NO (If "YES," also complete VA Form 21P-0969, Income and Asset Statement)

IMPORTANT INFORMATION
VA MATCHES INCOME INFORMATION REPORTED WITH FEDERAL TAX INFORMATION. REPORT ALL INCOME YOU AND YOUR
DEPENDENTS RECEIVE ON THE APPROPRIATE SECTIONS OF THIS FORM AND VA FORM 21P-0969, INCOME AND ASSET STATEMENT,
IF APPROPRIATE.
38A. OTHER THAN SOCIAL SECURITY, DO YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME?
YES

NO

38B. OTHER THAN SOCIAL SECURITY, DID YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME LAST YEAR?
YES
NO
38C. DO YOU OR YOUR DEPENDENTS HAVE MORE THAN $10,000.00 IN ASSETS? (Note: Assets are all the money and property you or your dependents own.
Assets do not include your/your family's primary residence or personal effects such as appliances and vehicles your or your dependents need for transportation)
YES

NO

38D. IN THE THREE CALENDAR YEARS BEFORE THIS YEAR, DID YOU OR YOUR DEPENDENTS TRANSFER ANY ASSETS? (Examples of asset transfers include
giving them away, selling them, purchasing an annuity, or using them to establish a trust)
YES

NO

38E. DID YOU ANSWER "YES" TO ANY OF THE ITEMS 38A THRU 38D?
YES

NO

(If "YES," you must also complete VA Form 21P-0969, Income and Asset Statement)

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 43A THRU 43C ON PAGE 10.
PAGE 8

PART IX - INFORMATION ABOUT YOUR UNREIMBURSED MEDICAL OR OTHER EXPENSES
Family medical expenses and certain other expenses you actually paid may be deductible from your income. Show the amount of unreimbursed
medical expenses, including the Medicare deduction, you paid over the last year (or expect to pay and continue indefinitely) for yourself,
dependents you are under obligation to support, or relatives who are members of your household. Also, show unreimbursed last illness and burial
expenses and educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are unreimbursed amounts you paid for
the last illness and burial of a spouse or child at any time prior to the end of the year following the year of death. Educational or vocational
rehabilitation expenses are amounts you paid for courses of education including tuition, fees, and materials. Do not include any expenses for which
you or your dependents were/will be reimbursed. Please be sure to complete all 6 criteria below (if applicable).
If more space is needed, complete and attach a separate VA Form 21P-8416, Medical Expense Report.
IMPORTANT: If you are claiming expenses for in-home care or an assisted living facility, adult day care, or similar facility, you must
complete the applicable worksheet(s) on pages 11 and 12.
39A. AMOUNT YOU PAID

39B. DATE
PAID
(Month, year)

39C. HOURLY
39D. PURPOSE
RATE/HOURS
(Doctor's fees, hospital charges,
(In-home
attorney fees, etc.)
attendant only)

39E. PAID TO

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

39F. PERSON FOR WHOM EXPENSE
PAID (Self, spouse, child)

PART X - DIRECT DEPOSIT
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 40, 41 and 42 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.
40. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)
CHECKING
(Account Number)

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

SAVINGS
(Account Number)
41. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank

where you want your direct deposit to go)

42. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the

bottom left of your check or savings deposit slip)

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 43A THRU 43C ON PAGE 10.
PAGE 9

PART XI - CERTIFICATION, AUTHORIZATION, AND SIGNATURE(S)
I certify that the statements in this document are true and complete to the best of my knowledge and belief. 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.
IMPORTANT - If you sign with an "X", then you must have 2 people witness your signature. They must then print their names and addresses and sign the form.
43A. VETERAN'S SIGNATURE (Do not print) (Please sign in ink)

43B. VETERAN'S PRINTED NAME

43C. DATE SIGNED

44A. SIGNATURE OF WITNESS (Do not print)

44B. PRINTED NAME AND ADDRESS OF WITNESS

45A. SIGNATURE OF WITNESS (Do not print)

45B. PRINTED NAME AND ADDRESS OF WITNESS

PART XII - REMARKS
(Use this space for any additional statements that you would like to make concerning your application for Compensation and/or Pension)
46. REMARKS (If you need more space you may attach a separate sheet of paper)

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 to which you are not entitled.

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 43A THRU 43C ON THIS PAGE.
PAGE 10

WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY
NOTE: Only complete this worksheet if you are claiming expenses for an assisted living facility, adult day care or similar facility.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder.
INSTRUCTIONS: Use this worksheet if you are claiming a disabled person's care in an assisted living facility, adult day care, or similar facility as unreimbursed
medical expenses. Follow the steps below to determine whether VA may deduct all or some of your out-of-pocket payments to the facility.

STEP 1. Are the expenses you wish to claim due to the disabled person's treatment in a hospital, inpatient treatment center,
nursing home, or VA approved medical foster home?
YES

NO

(If "NO," continue to Step 2)

(If "YES," all payments to the facility qualify as medical expenses in Items 39A thru 39F. You are finished completing this worksheet)

STEP 2. Do all of the following apply to the facility?
• The facility is licensed (if the State or Country requires it)
• The facility's staff (or the facility's contracted staff) provides the disabled person with
health care or custodial care or both.
• If the facility is residential, it is staffed 24 hours per day with caregivers
YES

NO

(If "NO," payments to the facility do not qualify as medical expenses. You are finished completing this worksheet)

STEP 3. Are you (the veteran) the disabled person?
YES

NO

(If "NO," skip to Step 6)

STEP 4. Did you claim special monthly pension on Page 7, Item 33 of the attached form?
YES

NO

(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amount you pay the facility for
health care services or assistance with ADLs provided by a health care provider in Items 39A thru 39F. Skip to Step 8)

STEP 5. If you answered "YES" in Step 2, you stated that the facility provides you with health care and/or custodial care.
Is this the primary reason you live in the facility (or attend day care in the facility)?
YES

(If "YES," all payments to this facility may qualify as medical expenses in Items 39A thru 39F if VA rates you as eligible for special
monthly pension. Please report separately in Items 39A thru 39F applicable amounts you pay the facility for: (1) lodging and meals, (2) health
NO care services or assistance with ADLs provided by a health care provider, and (3) custodial care. Skip to Step 8)
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Please report separately in Items 39A thru 39F
applicable amounts you pay the facility for: (1) health care services or assistance with ADLs provided by a health care provider;
and (2) custodial care. Skip to Step 8)

STEP 6. Does the disabled person require the health care services or custodial care that the facility provides to him or her because of the disabled
person's mental or physical disability?

YES

NO

(If "YES," you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care services
or custodial care that the facility provides to him or her because of mental or physical disability, and (2) describes the mental or physical
disabilty)
(If "NO," claim payments you pay this facility for health care services or assistance with ADLs provided by a health care provider in
Items 39A thru 39F. Skip to Step 8)

STEP 7. If you answered "YES" in Step 2, you stated that the facility provides the disabled person with health care and/or custodial care.
Is this the primary reason the disabled person lives in the facility (or attends day care in the facility)?
(If "YES," claim all payments to this facility (to include meals and lodging) as medical expenses in Items 39A thru 39F)
YES

NO

(If "NO," only claim payments you pay the facility for assistance with health care and/or assistance with custodial care as medical
expenses in Items 39A thru 39F. Payment to this facility for meals and lodging do not qualify)

STEP 8. Facility Certification: Please submit a current statement showing the fees the claimant pays to your facility and a breakdown of the care received.
I CERTIFY that the information stated within this WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY is accurate and
reflects the current environment pertaining to _______________________________________________________________________________________
(Name of person staying at your facility)

and his or her care at this facility_________________________________________________________________________________________________.
(Name and address of facility)

__________________________________________________________________
(Name, Signature and Title of Person Certifying for the Facility)

___________________
(Date Certified)

Page 11

WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
NOTE: Only complete this worksheet if you are claiming expenses for in-home care.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder
IMPORTANT: The following activities are examples of Instrumental Activities of Daily Living (IADLs) for VA purposes. VA generally does not recognize assistance
with these activities as medical expenses: (1) Shopping; (2) Food Preparation; (3) Housekeeping; (4) Laundering; (5) Handling medications; (6) Using the telephone;
(7) Transportation (except for medical purposes such as transportation to a doctor's appointment).
INSTRUCTIONS: Use this worksheet if you are claiming payments to a disabled person's in-home attendant as an unreimbursed medical expense.
Follow the steps below to determine whether or not:
• the attendant must be a health care provider for VA purposes and
• VA may deduct payment for assistance with IADLs as well as assistance with ADLs and custodial care

STEP 1. Are you (the veteran) the disabled person?
YES

NO

(If "NO," skip to Step 4)

STEP 2. Did you claim special monthly pension on Page 7, Item 33 of the attached form?
YES

NO

(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in
Items 39A thru 39F applicable amounts you pay an in-home attendant for: (1) health care services or assistance with ADLs provided by
a health care provider and (2) custodial care. Skip to Step 6)

STEP 3. Is the primary responsibility of the in-home attendant to provide you with health care or custodial care?
YES

NO

(If "YES," payments to this in-home attendant may qualify as medical expenses in Items 39A thru 39F if VA rates you as eligible for
special monthly pension. Please report separately in Items 39A thru 39F amounts you pay an in-home attendant for: (1) health-care
services or assistance with ADLs provided by a health care provider, (2) assistance with IADLs, and (3) custodial care. Skip to Step 6)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in
Items 39A thru 39F applicable amounts you pay an in-home attendant for: (1) health care services or assistance with
ADLs provided by a health care provider and (2) custodial care. Skip to Step 6)

STEP 4. Does the disabled person require the health care services or custodial care that the in-home attendant provides to him or her because of the
disabled person's mental or physical disability?
YES

NO

(If "YES," you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care
services or custodial care that the in-home attendant provides to him or her because of mental or physical disability, and (2) describes
the mental or physical disability)
(If "NO," the attendant must be a health care provider. Only report payments to the in-home attendant for health care services or
assistance with ADLs provided by the health care provider as medical expenses in Items 39A thru 39F. Payments for assistance with
IADLs do not qualify as medical expenses. Skip to Step 6)

STEP 5. Is the primary responsibility of the in-home attendant to provide the disabled person with health care or custodial care?
YES

NO

(If "YES," payments to the in-home attendant qualify as medical expenses (even assistance with IADLs) and can be reported in
Items 39A thru 39F)
(If "NO," report payments to this in-home attendant for health care and/or custodial care as medical expenses in Items 39A thru 39F.
Payment for assistance with IADLs do not qualify as a medical expense)

STEP 6. Check all activities below that the attendant assists the veteran or disabled person with:
ADLs:

EATING

BATHING/SHOWERING

DRESSING

IADLs:

SHOPPING

FOOD PREPARATION

HOUSEKEEPING

USING THE TELEPHONE

TRANSFERRING

USING THE TOILET

LAUNDERING

MANAGING
FINANCES

HANDLING MEDICATIONS

TRANSPORTANTION FOR NON-MEDICAL PURPOSES

STEP 7. In-Home Attendant Certification: Please submit a current breakdown of the time the attendant spends assisting the veteran or disabled person
with health care services, ADLs and IADLs.
I CERTIFY that the information stated within this WORKSHEET FOR IN-HOME ATTENDANT EXPENSES is accurate and
reflects the current environment pertaining to _______________________________________________________________________________________
(Name of Person Requiring Care)

and his or her care from_________________________________________________________________________________________________.
(Name of Attendant)

__________________________________________________________________
(Name, Signature and Title of Certifying Official)

___________________
(Date Certified)

Page 12