Form VA Form 21-0304 VA Form 21-0304 Application for Benefits for a Qualifying Veteran's Chil

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),
• have been conceived after the date the veteran first served in the RVN during the period 2/28/61 to 5/7/75, and
• have certain birth defects identified by the Secretary of Veterans Affairs as resulting in permanent physical or mental disability.
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.
Note: Completion of VA Form 21-0304, Application for Benefits for a Qualifying Veteran's Child Born with Disabilities, 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, children of veterans who served in the Republic of Vietnam (RVN), or
in or near the demilitarized zone (DMZ) in Korea, as well as children of certain veterans who served in Thailand.
For eligibility based on a parent's service in Vietnam or Korea, the child must:
• be the biological child of a veteran who served in the RVN, or a
veteran who served in or near the DMZ in Korea and was exposed to herbicides, and
• have been conceived after the date the veteran first served in the RVN during the period 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 physician or government,
or private institution examination reports.
For eligibility based on a parent's service in Thailand, the child must:
• be the biological child of a veteran who served at one of the following Royal Thai Air Force Bases (RTAFB):
U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, or Don Muang as an Air Force security policeman,
security patrol dog handler, member of the security police squadron, or otherwise near the air base perimeter, and
• have been conceived after the date the veteran first served on a RTAFB, and
• have any type of spina bifida other than spina bifida occulta. The diagnosis may be established by private physician or
government or private institution examination reports.

General Information
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)
P. O. Box 25126
Denver, CO 80225
VA FORM 21-0304, XXX XXXX

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OMB Approved 2900-0572
Respondent Burden: 10 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR BENEFITS FOR A QUALIFYING VETERAN'S CHILD
BORN WITH DISABILITIES
INSTRUCTIONS: Read the Privacy Act and Respondent Burden on Page 4 before completing the form.
Complete as much of Section I as possible. The information requested will help process your claim for
benefits. After completing the form, mail to: VA Regional Office, Veterans Service Center (339/21),
P. O. Box 25126, Denver, CO 80225.
SECTION I: CHILD'S IDENTIFICATION INFORMATION
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.
1. NAME OF CHILD (First, Middle Initial, Last)

3. CHILD'S DATE OF BIRTH

2. SOCIAL SECURITY NUMBER OF CHILD (Required)

Month

4. CHILD'S PLACE OF BIRTH (City and State, County and State, or City and Country)

Day

Year

5. TELEPHONE NUMBER OF CHILD (Include Area Code)

6. CHILD'S MAILING ADDRESS (Number and Street or Rural Route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City
Country

State/Province

ZIP Code/Postal Code

SECTION II: RELATIONSHIP WITH PARENTS
7. NAME(S), ADDRESS, TELEPHONE NUMBER, AND VETERAN STATUS OF NATURAL PARENT(S)
(Please provide information for both parents)
A. NAME OF PARENT 1 (First, Middle Initial, Last)

B. NAME OF PARENT 2 (First, Middle Initial, Last)

C. ADDRESS OF PARENT 1 (Number and Street or Rural Route, P.O. Box, City,

D. ADDRESS OF PARENT 2 (Number and Street or Rural Route, P.O. Box, City,

E. TELEPHONE NUMBER OF PARENT 1 (Include Area Code)

F. TELEPHONE NUMBER OF PARENT 2 (Include Area Code)

G. VIETNAM, THAILAND, OR KOREA SERVICE OF PARENT 1

H. VIETNAM, THAILAND, OR KOREA SERVICE OF PARENT 2

State, ZIP Code and Country)

YES

NO

(If "Yes," provide dates in 7I)

State, ZIP Code and Country)

YES

NO

(If "Yes," provide dates in 7J)

I. PROVIDE THE DATES THAT PARENT 1 WAS IN VIETNAM, THAILAND, OR KOREA J. PROVIDE THE DATES THAT PARENT 2 WAS IN VIETNAM, THAILAND, OR KOREA
FROM:

TO:

FROM:

8A. SOCIAL SECURITY NUMBER OF PARENT 1

8B. SOCIAL SECURITY NUMBER OF PARENT 2

9A. VA CLAIM NUMBER OF PARENT 1 (If applied previously)

9B. VA CLAIM NUMBER OF PARENT 2 (If applied previously)

VA FORM
XXX XXXX

21-0304

SUPERSEDES VA FORM 21-0304, JUN 2016.

TO:

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10. IF CHILD IS UNDER AGE 18 & CUSTODIAN/GUARDIAN IS OTHER THAN NATURAL PARENT (Complete Items 10A, 10B & 10C)
A. NAME OF CUSTODIAN/GUARDIAN OF CHILD

C. ADDRESS OF CUSTODIAN/GUARDIAN OF CHILD

B. RELATIONSHIP TO CHILD
ADOPTIVE PARENT

GUARDIAN

OTHER (Specify)

11. IF CHILD IS AGE 18 OR OLDER (Complete Items 11A, 11B & 11C, if applicable)
A. HAS THE CHILD BEEN DECLARED INCOMPETENT?
YES

NO

(If "Yes," complete Items 11B and 11C)

B. NAME AND ADDRESS OF THE COURT THAT MADE THE FINDING OF INCOMPETENCY

C. NAME AND ADDRESS OF CUSTODIAN/GUARDIAN

SECTION III: CLAIM INFORMATION
12A. DISABILITIES CLAIMED

12B. NAME AND PLACE FIRST DIAGNOSED

12C. DATE FIRST DIAGNOSED

13A. NAME OF PRIMARY HEALTH CARE PROVIDER

13B. ADDRESS OF PRIMARY HEALTH CARE PROVIDER

14A. NAME(S) AND PLACE(S) OF MOST RECENT TREATMENT

14B. DATE(S) OF TREATMENT

SECTION IV: DIRECT DEPOSIT INFORMATION
The Department of the 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 16A, 16B and 16C
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 the Treasury at 1-888-224-2950.
They will encourage your participation in EFT and address any questions or concerns you may have.
15. BY CHECKING THE BOX I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT
(NOTE: If you check this box you may skip to Section V)
16A. ACCOUNT NUMBER (Check only one box and provide the account number)

Account No.:

CHECKING

SAVINGS

16B. NAME OF FINANCIAL INSTITUTION (Provide the name of the bank where you want your direct deposit)

16C. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the bottom left of your check)

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SECTION V: CLAIM CERTIFICATIONS AND SIGNATURES

I/WE, the undersigned, hereby authorize the hospital OR physician shown in Items 12B, 13A and 14A 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.
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 Items 7A and/or 7B.
17A. SIGNATURE OF ADULT CHILD OR PARENT OR CUSTODIAN/GUARDIAN

17B. DATE SIGNED (MM/DD/YYYY)

SECTION VI: WITNESSES TO SIGNATURE
18A. SIGNATURE OF WITNESS (Sign in ink. If adult child or parent or custodian/guardian

18B. PRINTED NAME AND ADDRESS OF WITNESS

19A. SIGNATURE OF WITNESS (Sign in ink. If adult child or parent or custodian/guardian

19B. PRINTED NAME AND ADDRESS OF WITNESS

signed above using an "X")

signed above using an "X")

SECTION VII: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE
(NOTE: REQUIRED ONLY IF ITEM 17A IS BLANK)
I certify that by signing on behalf of the claimant, that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on
behalf of aclaimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a
spouse or other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND,
that the claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to
certify that the statements made on the form are true and complete; OR, is physically unable to sign this form.
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that
VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant
if necessary. Examples of evidence which VA may request include: Social Security number (SSN) or Taxpayer Identification Number (TIN); a
certificate or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/time
stamp; copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and your
authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the
care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
20A. ALTERNATE SIGNER SIGNATURE (REQUIRED) (Sign in ink)

20B. DATE SIGNED (MM/DD/YYYY)

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.
PRIVACY ACT NOTICE: VA will not disclose the 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, 58VA21/22/28, Compensation,
Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required in order to
obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 U.S.C. 5101 (c) (1). The
VA will not deny an individual benefit for refusing to provide your 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 your eligibility for benefits for children with certain disabilities who are born of Vietnam veterans
or certain Thailand or 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.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.
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