VA Form 21-526EZ Application for Disability Compensation and Related Comp

NOTICE TO VETERAN/SERVICE MEMBER OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
VETERANS DISABILITY COMPENSATION AND RELATED COMPENSATION BENEFITS
This notice provides information regarding the evidence necessary to substantiate a claim for:
Disability Service Connection
Compensation Claims Submitted Prior to Discharge
Compensation under 38 U.S.C. 1151
Automobile Allowance/Adaptive Equipment
Secondary Service Compensation
Temporary Total Disability Rating

Special Monthly Compensation
Benefits Based on a Veteran's Seriously Disabled Child
Increased Disability Compensation
Individual Unemployability
Specially Adapted Housing/Special Home Adaptation

When to Use this Form
Use this notice and the attached application to submit a claim for veterans' disability compensation and related compensation benefits. This
notice informs you of the evidence necessary to decide your claim. After you submit your claim on the attached application you will not receive
an initial letter regarding your claim. You do not need to submit another application.
If you are filing a claim for increased disability
compensation or disagree with an evaluation decided
more than one year ago ....
If you disagree with an evaluation decided within the
past year and have new and relevant evidence OR
If you are filing a supplemental claim (a claim after an
initial claim for the same or similar benefit on the same
or similar basis was previously decided) ....

please complete and submit VA Form 21-526EZ,
Application for Disability Compensation and Related
Compensation Benefits.

please complete and submit VA Form 20-0995, Decision
Review Request: Supplemental Claim**

** You may also file a request for higher-level review or appeal to the Board of Veterans' Appeals. For additional information on all of these
different options, please visit https://benefits.va.gov/benefits/appeals.asp.
Want to apply electronically? You can apply online at www.va.gov. If you sign in or create an account at www.va.gov, we can prefill parts of your
application and save your work in progress. You can also upload all your supporting documents with your claim, and submit it through the Fully
Developed Claims (FDC) program, then track claim status online. Get Started at https://www.va.gov/disability/how-to-file-claim/.
NOTE: You may wish to contact an accredited veterans service officer (VSO) to assist you with your application. For a list of accredited veterans
service organizations go to https://www.va.gov/vso/. You may also contact your state office of veterans affairs at https://www.va.gov/statedva.htm,
should you need further assistance with the application process.
Want your claim processed faster? The FDC Program is the fastest way to get your claim processed without any risk to participate! To participate in
making a claim for veterans disability compensation or related compensation benefits, submit your claim in accordance with the "FDC Program" shown
on the following information pages 2 through 7. If you are making a claim for veterans non service-connected pension benefits, use VA Form
21P-527EZ, Application for Pension. If you are making a claim for survivor benefits, use VA Form 21P-534EZ, Application for DIC, Death Pension,
and/or Accrued Benefits. VA forms are available at www.va.gov/vaforms. A separate expedited claims processing program available for current active
duty Servicemembers is explained on page 5 under Compensation Claims Submitted Prior to Discharge.
NOTE: Participation in the FDC Program is optional and will not affect the benefits to which you are entitled. If you file a claim in the FDC Program
and it is determined that other records exist and VA needs the records to decide your claim, then VA will simply remove the claim from the FDC
Program and process it in the Standard Claim Process. If you wish to file your claim in the FDC Program, see FDC Program (Optional Expedited
Process) on page 2 . If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim Process on page 2.

SUBMITTING A CLAIM
When submitting a claim(s) for Veterans Disability Compensation and Related Compensation Benefits the following information tells you what you
need to do and what VA will do during the FDC Program (Optional Expedited Process) or the Standard Claim Process:
1. HOW TO SUBMIT A CLAIM
Submit your claim on a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits (Attached). Make sure
you complete and sign your application. The information on pages 2 through 8 describes the evidence you need to submit, how VA will help you
obtain evidence and what the evidence must show to support your claim.
2. WHAT YOU NEED TO DO
The table on page 2 describes the information and evidence you need to submit based on whether you wish to have your claim considered in the FDC
Program (Optional Expedited Process) or in the Standard Claim Process. You will need to indicate how you want your claim to be processed by
checking the appropriate box in Item 1, on page 9 of this form.
VA FORM
XXXX

21-526EZ

SUPERSEDES VA FORM 21-526EZ, SEP 2019.

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FDC Program (Optional Expedited Process)
You must:
• Submit all relevant private treatment records, if they exist
• Identify any relevant treatment records available at a Federal
Facility, such as a VA medical center
• Identify the location and sufficient information to obtain your
National Guard and Reserve personnel and service treatment
records (if applicable)
If your claim involves a disability that you had before entering service
and that was made worse by service, please provide any information or
evidence in your possession regarding the health condition that existed
before your entry into service.
NOTE: If you decide to submit your claim through the FDC Program,
please indicate FDC in Item 1 of the application on page 8.

Standard Claim Process
If you know of evidence not in your possession and want VA to try to get
it for you;
You must:
• Complete and sign 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), identifying any private medical
records you wish VA to request for you
• Give VA enough information about other relevant evidence so that we
can request it from the person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a fee to
provide it, or otherwise cannot get the evidence, VA will notify you and
provide you with an opportunity to submit the information or evidence. It
is your responsibility to make sure we receive all requested records that
are not in the possession of a Federal department or agency.
If your claim involves a disability that you had before entering service and
that was made worse by service, please provide any information or
evidence in your possession regarding the health condition that existed
before your entry into service.

You must:

You are strongly encouraged to:

• Send the information and evidence along with your claim

• Send any information or evidence as soon as you can

If you submit additional information or evidence after you submit your
"fully developed" claim, then VA will remove the claim from the FDC
Program (Optional Expedited Process) and process it in the Standard
Claim Process. If we decide your claim before one year from the date
we receive the claim, you will still have the remainder of the one-year
period to submit additional information or evidence necessary to
support the claim.

You have up to one year from the date we receive the claim to submit the
information and evidence necessary to support your claim. If within 30
days, you do not provide any evidence or do not provide us with the
information needed to assist you with obtaining evidence, we may decide
your claim prior to the expiration of the one year period. If we decide the
claim before one year from the date we receive the claim, you will still
have the remainder of the one year period to submit additional information
or evidence necessary to support the claim.

If any of the special circumstances in the table below titled "Special
Circumstances" applies to you;

If any of the special circumstances in the table below titled "Special
Circumstances" applies to you;

You must:

You are strongly encouraged to:

• Send the information and evidence identified in the "Special
Circumstances" table below at the same time as your claim

• Send the information and evidence identified in the "Special
Circumstances" table below at the same time as your claim. If you do
not submit the needed information or evidence with your claim but it is
needed to make a decision, VA will request it from you.

SPECIAL CIRCUMSTANCES
Under the special circumstances shown below, you must also submit along with your claim the following:
• If you were treated at a Veterans Center, submit a completed VA Form 21-4142, Authorization to Disclose Information to the
Department of Veterans Affairs (VA)
• If claiming dependents, submit a completed VA Form 21-686c, Application Request to Add and/or Remove Dependents. If claiming a
child in school between the ages of 18 and 23; also submit a completed VA Form 21-674, Request for Approval of School Attendance. If
claiming benefits for a seriously disabled (helpless) child, also submit all, relevant, private medical treatment records pertaining to the
child's pertinent disabilities
• If claiming Individual Unemployability, submit a completed VA Form 21-8940, Veteran's Application for Increased Compensation
Based on Unemployability
• If claiming Post-Traumatic Stress Disorder (PTSD), submit a completed VA Form 21-0781, Statement in Support of Claim for Service
Connection for Post-Traumatic Stress Disorder, or if claiming PTSD based on personal assault, submit a completed VA Form 21-0781a,
Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault
VA FORM 21-526EZ, XXXX

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SPECIAL CIRCUMSTANCES (Continued)
Under the special circumstances shown below, you must also submit along with your claim the following:
• If claiming Specially Adapted Housing or Special Home Adaptation, submit a completed VA Form 26-4555, Application in Acquiring
Specially Adapted Housing or Special Home Adaptation Grant
• If claiming Auto Allowance, submit a completed VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment
• If claiming additional benefits because you or your spouse require Aid and Attendance, submit a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance; or if claiming Aid and Attendance based on nursing home
attendance, a VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance
NOTE: VA forms are available online at www.va.gov/vaforms.
3. HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
The table below describes the information and evidence VA will assist you in obtaining based on whether you wish to have your claim considered in
the FDC Program (Optional Expedited Process) or in the Standard Claim Process.

FDC Program (Optional Expedited Process)
VA will:

Standard Claim Process
VA will:

• Retrieve relevant records from a Federal facility, such as a VA
medical center, that you adequately identify and authorized VA to
obtain
• Provide a medical examination for you, or get a medical opinion, if
we determine it is necessary to decide your claim

• Retrieve relevant records from a Federal facility, such as a VA medical
center, that you adequately identify and authorized VA to obtain
• Provide a medical examination for you, or get a medical opinion, if we
determine it is necessary to decide your claim
• Make every reasonable effort to obtain relevant records not held by a
Federal facility that you adequately identify and authorize VA to
obtain. These may include records from State or local governments and
privately held evidence and information you tell us about, such as a
private doctor or hospital records from current or former employers

4. WHERE TO SEND INFORMATION AND EVIDENCE
You may send your application and any evidence in support of your claim by using the following methods shown in the table below.

MAIL TO
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

SUBMIT ONLINE
VA gov: www.va.gov
Direct Upload: AccessVA

5. WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
The table below provides a guide to the evidence tables showing what evidence you must provide to support your claim.
If you are claiming...

See the evidence table titled...

You have a disability that was caused or aggravated by your service
Your service connected disability caused or aggravated an additional
disability
Your service connected disability has worsened
Compensation and you are a service person who is about to be discharged
Your service connected disability caused you to be hospitalized or to
undergo surgery or other treatment
Your service connected disability(ies) prevents you from getting or
keeping substantial employment
You have a disability caused or aggravated by VA medical treatment,
vocational rehabilitation, or compensated work therapy
Your service connected disability (ies) causes you to be in need of aid and
attendance or to be confined to your residence
Adapting and/or purchasing a residence
Adapting and/or purchasing a vehicle
A Severely Disabled Spouse
A Severely Disabled Child

Disability Service Connection

VA FORM 21-526EZ, XXXX

Secondary Service Connection
Increased Disability Compensation
Compensation Claims Submitted Prior to Discharge
Temporary Total Disability Rating
Individual Unemployability
Compensation Under 38 U.S.C. 1151
Special Monthly Compensation
Special Adapted Housing or Special Home Adaptation
Auto Allowance
Special Monthly Compensation
Helpless Child
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EVIDENCE TABLES
Disability Service Connection
To support a claim for service connection, the evidence must show:
• You had an injury in service, or a disease that began in or was made permanently worse during service, or there was an event in service that
caused an injury or disease; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent
symptoms of disability that are visible or observable; AND
• A relationship exists between your current disability and an injury, disease, symptoms, or event in service. This may be shown by medical
records or medical opinions or, in certain cases, by lay evidence.
To support a claim for service connection based upon a period of active duty for training, the evidence must show:
• You were disabled during active duty for training due to disease or injury incurred or aggravated in the line of duty; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent
symptoms of disability that are visible or observable; AND
• There is a relationship between your current disability and the disease or injury incurred or aggravated during active duty for training. This
may be shown by medical records or medical opinions or, in certain cases, by lay evidence.
To support a claim for service connection based upon a period of inactive duty training, the evidence must show:
• You were disabled during inactive duty training due to an injury incurred or aggravated in the line of duty or an acute myocardial infarction,
cardiac arrest, or cerebrovascular accident during inactive duty training; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent
symptoms of disability that are visible or observable; AND
• There is a relationship between your current disability and your inactive duty training. This may be shown by medical records or medical
opinions or, in certain cases, by lay evidence.
In order to file a supplemental claim, you must submit or identify new and relevant evidence.
• To qualify as new, the evidence must not have been part of the evidentiary record at the time of the prior decision.
• In order to be considered relevant, the additional evidence must tend to prove or disprove a matter at issue in the claim.
Presumptive Service Connection
To support a claim for presumptive service connection the evidence must show:
• You served in a recognized location that qualifies you for the presumption of exposure AND
• You have a current disability that qualifies you for the presumption of service connection. This may be shown by medical evidence or by lay
evidence of persistent and recurrent symptoms of disability that are visible or observable.
Under certain circumstances, VA may presume that certain current diseases were caused by service, even if there is no specific evidence proving
this in your particular claim. Service connection is presumed for certain diseases for the following veterans:
• Former prisoners of war;
• Veterans who have certain chronic or tropical diseases that become evident within a specific period of time after discharge from service;
• Veterans who were exposed to ionizing radiation, mustard gas, or Lewisite while in service:
• Veterans who were exposed to certain herbicides, such as by service in/on;
o
Vietnam or qualifying offshore waters, from January 9, 1962, through May 7, 1975;
o
A unit determined by VA or the Department of Defense, to have operated in the Korean DMZ, from September 1, 1967, through
August 31, 1971;
o
Thailand at any United States or Royal Thai base from January 9, 1962, through June 30, 1976;
o
Laos, from December 1, 1965, through September 30, 1969;
o
Cambodia at Mimot or Krek, Kampong Cham Province, from April 16, 1969, through April 30, 1969;
o
Guam or American Samoa, or in the territorial waters thereof, from January 9, 1962, through July 31, 1980;
o
Johnston Atoll or on a ship that called at Johnston Atoll, from January 1, 1972, through September 30, 1977.
• Veterans who served at Camp Lejeune for no less than 30 days (consecutive or nonconsecutive) between August 1, 1953 and December 31,
1987; or
• Veterans who served in the Gulf War:
o
On or after August 2, 1990, and served in, including airspace above:
§
Bahrain, Iraq, the neutral zone between Iraq and Saudi Arabia, Kuwait; Oman; Qatar; Saudi Arabia; Somalia; United Arab
Emirates; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; the Red Sea; Afghanistan; Israel; Egypt;
Turkey; Syria; or Jordan; or
o
On or after September 11, 2001, and served including airspace above:
§
Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Syria, Yemen, or Uzbekistan.

VA FORM 21-526EZ, XXXX

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EVIDENCE TABLES (Continued)
Secondary Service Connection
To support a claim for compensation based upon an additional disability that was caused or aggravated by a service-connected disability, the
evidence must show:
• You currently have a physical or mental disability shown by medical evidence or by lay evidence of persistent and recurrent symptoms of
disability that are visible or observable, in addition to your service-connected disability; AND
• Your service-connected disability either caused or aggravated your additional disability. This may be shown by medical records or medical
opinions or, in certain cases, by lay evidence. However, VA may presume service-connection for cardiovascular disease developing in a
claimant with certain service-connected amputation(s) of one or both lower extremities.
Increased Disability Compensation
If VA previously granted service connection for your disability and you are seeking an increased evaluation of your service-connected disability, we
need medical or lay evidence to show a worsening or increase in severity and the effect that worsening or increase has on your ability to work.
Compensation Claims Submitted Prior to Discharge
Under the Benefits Delivery at Discharge (BDD) program you can submit a disability claim 90 to 180 days prior to your anticipated separation date
from active duty. Claims are accepted from active duty Servicemembers, including reservists serving on active duty in an Active Guard Reserve
(AGR) role under 10 U.S.C. and full-time National Guard members serving in an AGR role under 32 U.S.C.
BDD program participants can have their VA medical examinations conducted while they are still on active duty. You are encouraged to file your
claim as close to the 180 day mark as possible to ensure your examinations can be scheduled and completed prior to your discharge from active duty.
The BDD program requires that Servicemembers be available to report for examinations for 45 days following submission of a disability claim.
Claims and additional contentions received with less than 90 days remaining on active duty, claim types that are excluded from the BDD program, or
where the Servicemember is unable to report for an examination within the BDD required time frame will be processed under the standard VA
claims process, the Fully Developed Claim (FDC) program or any other qualifying program.
BDD Program Criteria for Claim(s) for Disability Compensation and Related Compensation Benefits Submitted Prior to Separation from
Active Duty:
• be within 90 to 180 days of discharge;
• be available to report for examinations for 45 days following the submission of a disability claim;
• submit copies of service treatment records for the current period of service with the BDD claim;
• provide an anticipated release from active duty date, and
• complete a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits
Temporary Total Disability Rating
In order to support a claim for a temporary total disability rating due to hospitalization, the evidence must show:
• You were treated for more than 21 days for a service-connected disability at a VA or other approved hospital; OR
• You underwent hospital observation at VA expense for a service-connected disability for more than 21 days.
In order to support a claim for a temporary total disability rating due to surgical or other treatment performed by a VA or other approved
hospital or outpatient facility, the evidence must show:
• The surgery or treatment was for a service-connected disability; AND
• The surgery required convalescence of at least one month; OR
• The surgery resulted in severe postoperative residuals, such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic
immobilizations, house confinement, or the required use of a wheelchair or crutches; OR
• One major joint or more was immobilized by a cast without surgery.
Individual Unemployability
In order to support a claim for a total disability rating based on individual unemployability, the evidence must show:
• That your service-connected disability or disabilities are sufficient, without regard to other factors, to prevent you from performing the mental
and/or physical tasks required to get or keep substantially gainful employment; AND
• Generally, you meet certain disability percentage requirements as specified in 38 Code of Federal Regulations 4.16 (i.e. one disability ratable
at 60 percent or more, OR more than one disability with one disability ratable at 40 percent or more and a combined rating of 70 percent or
more).
In order to support a claim for an extra-scheduler evaluation based on exceptional circumstances, the evidence must show:
• That your service-connected disability or disabilities present such an exceptional or unusual disability picture, due to such factors as marked
interference with employment or frequent periods of hospitalization, that application of the regular schedular standards is impractical.
VA FORM 21-526EZ, XXXX

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EVIDENCE TABLES (Continued)
Compensation Under 38 U.S.C. 1151
In order to support a claim for compensation under 38 U.S.C. 1151, the evidence must show that, as a result of VA hospitalization, medical or
surgical treatment, examination, or training, you have:
• An additional disability or disabilities; OR
• An aggravation of an existing injury or disease; AND
• The disability was the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment, or not a reasonably
expected result or complication of the VA care or treatment; OR
• The direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy program.
Special Monthly Compensation
In order to support a claim for increased benefits based on the need for aid and attendance, the evidence must show that, due to your serviceconnected disability or disabilities:
• You require the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing
yourself, attending to the wants of nature, adjusting prosthetic devices, or protecting yourself from the hazards of your daily environment (38
Code of Federal Regulation 3.352(a)); OR
• You are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed course of convalescence or
treatment (38 Code of Federal Regulation 3.352(a)).
In order to support a claim for increased benefits based on an additional disability or being housebound, the evidence must show:
• You have a single service-connected disability evaluated as 100 percent disabling AND an additional service-connected disability, or
disabilities, evaluated as 60 percent or more disabling; OR
• You have a single service-connected disability evaluated as 100 percent disabling AND, due solely to your service-connected disability or
disabilities, you are permanently and substantially confined to your immediate premises.
In order to support a claim for increased benefits based on your spouse's need for aid and attendance, per the provisions of 38 C.F.R. § 3.351(c),
the evidence must show:
• Your spouse is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual
field to 5 degrees or less; OR
• Your spouse is a patient in a nursing home because of mental or physical incapacity; OR
• Your spouse requires the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding,
dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the hazards of his or her daily environment
(See 38 C.F.R. § 3.352(a) for complete explanation).
IMPORTANT: For additional benefits to be payable for a spouse, the veteran must be entitled to compensation and evaluated as 30 percent or more
disabling.
Specially Adapted Housing or Special Home Adaptation
To support your claim for specially adapted housing (SAH), the evidence must show you are a:
• Veteran entitled to compensation under 38 U.S.C. Chapter 11 for a permanent and totally disabling qualifying condition; OR
• Servicemember on active duty who has a permanent and totally disabling qualifying condition incurred or aggravated in the line of duty.
To support that you have a qualifying condition for SAH the evidence must show:
• Amyotrophic lateral sclerosis (ALS); OR
• Loss (amputation) or loss of use of:
o both lower extremities; OR
o one lower extremity and one upper extremity affecting balance or propulsion; OR
o one lower extremity plus residuals of organic disease or injury affecting balance or propulsion creating a need for regular, constant use of a
wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other methods may occasionally be
possible); OR
• Loss or loss of use of both upper extremities precluding use of the arms at or above the elbow; OR
• Permanent but not total disability due to blindness in both eyes, (having central visual acuity of 20/200 or less in the better eye with the use of
a standard correcting lens); OR
• A severe burn injury, meaning full thickness or sub-dermal burns that have resulted in contractures with limitation of motion of:
o two or more extremities; OR
o at least one extremity and the trunk.

VA FORM 21-526EZ, XXXX

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EVIDENCE TABLES (Continued)
Specially Adapted Housing or Special Home Adaptation (Continued)
To support your claim for SAH the evidence may alternatively show you are a:
• Veteran who served and became permanently disabled from a qualifying condition on or after September 11, 2001; OR
• Servicemember on active duty who was permanently disabled in the line of duty from a qualifying condition on or after the same date.
To support that you have a qualifying condition under the alternative service criteria the evidence must show:
• Loss (amputation) or loss of use of:
o

one or more lower extremities, severely affecting the functions of balance or propulsion and creating a need for regular, constant use of a
wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other methods may occasionally be
possible).

To support your claim for a special home adaptation (SHA) grant the evidence must show you are a:
• Veteran entitled to compensation under 38 U.S.C. Chapter 11 for a qualifying condition; OR
• Servicemember on active duty who has a qualifying condition incurred or aggravated in the line of duty.
To support that you have a qualifying condition for SHA the evidence must show:
• the loss, or permanent loss of use, of at least a foot or a hand; OR
• Permanent and total disability from loss, or loss of use, of both hands; OR
• Permanent and total disability from a severe burn injury meaning
o

deep partial thickness burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one
extremity and the trunk; OR

o

full thickness or sub-dermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk; OR

o

residuals of inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease).

Auto Allowance
To support a claim for automobile allowance or adaptive equipment, the evidence must show that you have a service-connected disability resulting in:
• the loss, or permanent loss of use, of at least a foot or a hand; OR
• permanent impairment of vision of both eyes, resulting in:
o vision of 20/200 or less in the better eye with corrective glasses; OR
o vision of 20/200 or better, if there is a severe defect in your peripheral vision; OR
• deep partial thickness or full thickness burns resulting in scar formation that cause contractures and limit motion of one or more extremities of
the trunk and preclude effective operation of an automobile; OR
• amyotrophic lateral sclerosis (ALS).
NOTE - You may be entitled to only adaptive equipment if you have ankylosis ("freezing") of at least one knee or one hip due to service-connected
disability. Medical evidence, including a VA examination, will show these things. VA will provide an examination if it determines that one is
necessary.
Helpless Child
To support a claim for benefits based on a veteran's child being helpless, the evidence must show that the child, before his or her 18th birthday,
became permanently incapable of self-support due to a mental or physical disability.
IMPORTANT: For additional benefits to be payable for a child, the veteran must be entitled to compensation and evaluated as 30 percent or more
disabling.
How VA determines the effective date
If we grant your claim, the beginning date of your entitlement or increased entitlement to benefits will generally be based on the following factors:
• When we received your claim, OR
• When the evidence shows a level of disability that supports a certain rating under the rating schedule
If VA received your claim prior to or within one year of your separation from the military, entitlement will be from the day following the date of your
separation as long as the disability was present at that time.

VA FORM 21-526EZ, XXXX

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EVIDENCE TABLES (Continued)
How VA determines the disability rating
When we find disabilities to be service-connected, we assign a disability rating. That rating can be changed if there are changes in your condition.
Depending on the disability involved, we will assign a rating from 0 percent to as much as 100 percent. VA uses a schedule for evaluating disabilities
that is published as title 38, Code of Federal Regulations, Part 4. In rare cases, we can assign a disability level other than the levels found in the
schedule for a specific condition if your impairment is not adequately covered by the schedule.
We consider evidence of the following in determining disability rating:
• Nature and symptoms of the condition;
• Severity and duration of the symptoms; AND
• Impact of the condition and symptoms on employment.
Examples of evidence that you should tell us about or give to us that may affect how we assign a disability evaluation include the following:
• Information about on-going treatment records, including VA or other Federal treatment records, you have not previously told us about;
• Social Security determinations;
• Statements from employers as to job performance, lost time, or other information regarding how your condition(s) affect your ability to work;
OR
• Statements discussing your disability symptoms from people who have witnessed how the symptoms affect you.
For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/.
For more information on VA benefits, visit our web site at www.va.gov.
For additional information or questions contact VA online through Ask VA:https://www.va.gov/contact-us or call us toll-free at 800-827-1000 (TTY:711).
VA forms are available at www.va.gov/vaforms.

VA FORM 21-526EZ, XXXX

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OMB Control No. 2900-0747
Respondent Burden: 25 minutes
Expiration Date: XXXXX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR DISABILITY COMPENSATION AND RELATED
COMPENSATION BENEFITS

IMPORTANT: Please read the Privacy Act and Respondent Burden on page 14 before completing the form. Use this form to
determine your eligibility for compensation. For more information, you can contact us online through Ask VA:
https://ask.va.gov/. Ask us a question online or call us toll-free at 1-800-827-1000 (TTY: 711). If you prefer you may complete
and submit the form online at www.va.gov. VA forms are available at www.va.gov/vaforms.
1. SELECT THE TYPE OF CLAIM PROGRAM/PROCESS THAT APPLIES TO YOU Note: Your claim will be processed as
described on pages 1 - 8 unless one of the following special programs is selected. See instruction pages 1-3 for definitions of the Fully
Developed Claim (FDC) Program (Optional Expedited Process) or the Standard Claim Process.
FULLY DEVELOPED CLAIM (FDC) PROGRAM

STANDARD CLAIM PROCESS

IDES (Select this option only if you have been referred to the IDES Program by your Military Service Department)
BDD Program Claim (Select this option only if you meet the criteria for the BDD Program specified on
Instruction Page 5)

SECTION I: IDENTIFICATION AND CLAIM INFORMATION
(If claim is not an original claim, only Section I, IV (if applicable), V and a signature are required)
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.
2. VETERAN/SERVICEMEMBER'S NAME (First, Middle Initial, Last)

3. VETERAN'S SOCIAL SECURITY NUMBER (SSN)

5. VA FILE NUMBER

4. HAVE YOU EVER FILED A CLAIM WITH VA?
YES

6. DATE OF BIRTH (MM-DD-YYYY)

8. BDD CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF
RELEASE FROM ACTIVE DUTY (MM-DD-YYYY)

(If "Yes," provide your file
number in Item 5)
7. VETERAN'S SERVICE NUMBER (If applicable)
NO

9. TELEPHONE NUMBER (Optional) (Include Area Code)

Enter International Phone Number (If applicable)
10. CURRENT 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
11. EMAIL ADDRESS (Optional)

ZIP Code/Postal Code

I agree to receive electronic correspondence from VA in regards to my claim.

12. IF YOU ARE CURRENTLY A VA EMPLOYEE, CHECK THE BOX (Includes Work Study/Internship)? (If you are not a VA employee skip to Section II, if applicable)

SECTION II: CHANGE OF ADDRESS
NOTE: If you are temporarily or permanently changing your address, complete Items 13A through 13C.
13A. TYPE OF ADDRESS CHANGE (Complete if applicable) (Check only one box)
TEMPORARY

PERMANENT

13B. NEW ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

13C. EFFECTIVE DATE(S) OF NEW ADDRESS (If your change of address is temporary, complete both the beginning and ending date of your temporary address)
(If your change of address is permanent, please enter your effective date in the beginning date only)
Month
BEGINNING DATE:
VA FORM
XXXX

21-526EZ

Day

Year

Month

Day

Year

ENDING DATE:
SUPERSEDES VA FORM 21-526EZ, SEP 2019.

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VETERANS SOCIAL SECURITY NO.

SECTION III: HOMELESS INFORMATION
IMPORTANT: The following questions (Items 14A through 14F) should only be completed if you are currently homeless or at risk of becoming homeless.
If this item does not apply to you, skip to Section IV.
14A. ARE YOU CURRENTLY HOMELESS?

14B. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:
LIVING IN A HOMELESS SHELTER

YES

(If "Yes," complete Item 15B regarding your living situation)

NOT CURRENTLY IN A SHELTERED ENVIRONMENT (e.g., living in a car
or tent)

NO

STAYING WITH ANOTHER PERSON
FLEEING CURRENT RESIDENCE
OTHER (Specify)
14D. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:

14C. ARE YOU CURRENTLY AT RISK OF BECOMING HOMELESS?
YES

HOUSING WILL BE LOST IN 30 DAYS

(If "Yes," complete Item 15D regarding your living situation)

LEAVING PUBLICLY FUNDED SYSTEM OF CARE (e.g., homeless
shelter)

NO

OTHER (Specify)

14E. POINT OF CONTACT (Name of person VA can contact in order to get in touch with you)

14F. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If
applicable)

SECTION IV: EXPOSURE INFORMATION
15A. ARE YOU CLAIMING ANY CONDITIONS RELATED TO TOXIC EXPOSURES? Note: See Page 4 of the Instructions, for further information on the evidence needed to
support your claim for presumptive service connection. (You can also refer to the following websites for more information: PACT ACT (https://www.va.gov/resources/
the-pact-act-and-your-va-benefits/) and PUBLIC HEALTH MILITARY EXPOSURES (https://www.publichealth.va.gov/exposures/index.asp))
YES (If "Yes," complete Items 15B, 15C, 15D and 15E)
NO (If "No," skip to Item 16, Section V: Claim Information)
15B. DID YOU SERVE IN ANY OF THE FOLLOWING GULF WAR HAZARD LOCATIONS?
Iraq; Kuwait; Saudi Arabia; the neutral zone between Iraq and Saudi Arabia; Bahrain; Qatar; the United Arab Emirates; Oman; Yemen; Lebanon; Somalia; Afghanistan;
Israel, Egypt; Turkey; Syria; Jordan; Djibouti; Uzbekistan; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; the Red Sea.
YES

NO

WHEN WERE YOU EXPOSED? (MM/DD/YYYY)
15C. DID YOU SERVE IN ANY OF THE FOLLOWING HERBICIDE (e.g., Agent Orange) LOCATIONS?
Republic of Vietnam to include the 12 nautical mile territorial waters: Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek, Kampong Cham
Province; Guam or American Samoa, or in the teritorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarizerd zone.
Please list other location(s) where you served, if not listed above:
YES

NO

WHEN WERE YOU EXPOSED? (MM/DD/YYYY)
15D. HAVE YOU BEEN EXPOSED TO ANY OTHER EXPOSURES? (Check all that apply)
ASBESTOS

MUSTARD GAS

RADIATION

PFAS (Perfluoroalkyl and Polyfluoroalkyl substances)

CONTAMINATED WATER AT CAMP LAJEUNE

SHAD (Shipboard Hazard and Defense)

OTHER (Specify)
WHEN WERE YOU EXPOSED? (MM/DD/YYYY)
15E. IF YOU WERE EXPOSED MULIPLE TIMES, PLEASE PROVIDE THE ADDITIONAL DATES YOU WERE EXPOSED AND THE LOCATION

SECTION V: CLAIM INFORMATION
(For additional space, use Section XIII: Claim Information (Addendum))
16. LIST THE CURRENT DISABILITY(IES) OR SYMPTOMS THAT YOU CLAIM ARE RELATED TO YOUR MILITARY SERVICE AND/OR SERVICE-CONNECTED
DISABILITY(If applicable, identify whether a disability is due to a service-connected disability; confinement as a prisoner of war; exposure to Agent Orange, asbestos, mustard gas, ionizing
radiation, or Gulf War environmental hazards; or a disability for which compensation is payable under 38 U.S.C. 1151)
NOTE: List your claimed conditions below. See the following three examples for guidance on how to complete Section V.

EXAMPLES OF DISABILITY(IES)

EXAMPLES OF EXPOSURE
TYPE

EXAMPLES OF HOW THE
DISABILITY(IES) RELATES TO SERVICE

EXAMPLES OF DATES

Example 1. HEARING LOSS

NOISE

HEAVY EQUIPMENT OPERATOR IN SERVICE JULY 1968

Example 2. DIABETES

AGENT ORANGE

SERVICE IN VIETNAM WAR

DECEMBER 1972

INJURED LEFT KNEE WHEN BRACE ON
RIGHT KNEE FAILED

6/11/2008

Example 3. LEFT KNEE, SECONDARY TO RIGHT KNEE
VA FORM 21-526EZ, XXXX

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VETERANS SOCIAL SECURITY NO.

SECTION V: CLAIM INFORMATION (Continued)
(For additional space, use Section XIII: Claim Information (Addendum))
CURRENT DISABILITY(IES)

IF DUE TO EXPOSURE, EVENT, OR
INJURY, PLEASE SPECIFY
(e.g., Agent Orange, radiation,
toxic exposure)

EXPLAIN HOW THE DISABILITY(IES)
RELATES TO THE IN-SERVICE
EVENT/EXPOSURE/INJURY

APPROXIMATE DATE
DISABILITY(IES)
BEGAN OR WORSENED

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
17. LIST VA MEDICAL CENTER(S) (VAMC) AND DEPARTMENT OF DEFENSE (DOD) MILITARY TREATMENT FACILITIES (MTF) WHERE YOU RECEIVED TREATMENT
AFTER DISCHARGE FOR YOUR CLAIMED DISABILITY(IES) LISTED IN ITEM 16 AND PROVIDE APPROXIMATE BEGINNING DATE (Month and Year) OF
TREATMENT. IF ADDITIONAL SPACE IS NEEDED ATTACH A SEPARATE SHEET AND INCLUDE YOUR NAME, SOCIAL SECURITY NUMBER AND ITEM NUMBER.

NOTE: If treatment began from 2005 to present, you do not need to provide dates in Item 17B.
A. ENTER THE DISABILITY TREATED AND NAME/LOCATION OF THE TREATMENT FACILITY

B. DATE OF TREATMENT
(MM-YYYY)

C. CHECK THE BOX IF YOU DO
NOT HAVE DATE(S)
OF TREATMENT
Don't have date

Don't have date

Don't have date

NOTE: IF YOU WISH TO CLAIM ANY OF THE FOLLOWING, COMPLETE AND ATTACH THE REQUIRED FORM(S) AS STATED BELOW.
(VA forms are available at www.va.gov/vaforms)
For:

Required Form(s):

Supplemental Claims

VA Form 20-0995, Decision Review Request: Supplemental Claim

Dependents

VA Form 21-686c and, if claiming a child aged 18-23 years and in school, VA Form 21-674

Individual Unemployability

VA Form 21-8940 and 21-4192

Post-Traumatic Stress Disorder

VA Form 21-0781 or 21-0781a

Specially Adapted Housing or Special Home Adaptation

VA Form 26-4555

Auto Allowance

VA Form 21-4502

Veteran/Spouse Aid and Attendance benefits

VA Form 21-2680 or, if based on nursing home attendance, VA Form 21-0779

VA FORM 21-526EZ, XXXX

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VETERANS SOCIAL SECURITY NO.

SECTION VI: SERVICE INFORMATION
18A. DID YOU SERVE UNDER ANOTHER NAME?
YES (If "Yes," complete Item 18B)

NO

18B. LIST THE OTHER NAME(S) YOU SERVED UNDER:

(If "No," skip to Item 19A)
19B. COMPONENT

19A. BRANCH OF SERVICE
ARMY

NAVY

MARINE CORPS

AIR FORCE

COAST GUARD

SPACE FORCE

NOAA

USPHS

ACTIVE

20A. MOST RECENT ACTIVE SERVICE DATES (MM,DD,YYYY)
Month

ENTRY DATE:

RESERVES

NATIONAL GUARD

20B. PLACE OF LAST OR ANTICIPATED SEPARATION

Year

Day

EXIT DATE:
20C. DID YOU SERVE IN
A COMBAT ZONE
SINCE 9-11-2001?
YES

Day

Month
20D. ADDITIONAL PERIODS OF SERVICE (Indicate
enlistment and discharge date(s), if applicable)

Year

From:
To:

NO

21A. ARE YOU CURRENTLY SERVING OR HAVE YOU EVER SERVED IN
THE RESERVES OR NATIONAL GUARD?
YES

(If "Yes," complete Items 21B thru 21F)

NO

(If "No," skip to Item 22A)

21D. CURRENT OR LAST ASSIGNED NAME AND ADDRESS OF UNIT:

21B. COMPONENT

21C. OBLIGATION TERM OF SERVICE
Month

NATIONAL
GUARD

From:

RESERVES

To:

Day

Year

21F. ARE YOU CURRENTLY
RECEIVING INACTIVE DUTY
TRAINING PAY?

21E. CURRENT OR ASSIGNED PHONE
NUMBER OF UNIT (Include Area

Code)

YES
22A. ARE YOU CURRENTLY ACTIVATED ON FEDERAL
ORDERS WITHIN THE NATIONAL GUARD OR
RESERVES?
YES

(If "Yes," complete Items 22B & 22C)

22B. DATE OF ACTIVATION:
Month

Day

NO

22C. ANTICIPATED SEPARATION DATE:
Year

Day

Month

Year

NO
23B. DATES OF CONFINEMENT

23A. HAVE YOU EVER BEEN A PRISONER OF WAR?

From:

YES (If "Yes," complete Item 23B)

To:

Month

Day

Year

Month

Day

Year

Month

Day

Year

Month

Day

Year

NO

SECTION VII: SERVICE PAY (Retired Pay, Separation Pay, and Disability Severance Pay)
24A. ARE YOU RECEIVING MILITARY RETIRED PAY?
YES (If "Yes," complete Items 24C and 24D)
NO

24B. WILL YOU RECEIVE MILITARY RETIRED PAY IN THE FUTURE?
YES

NO
24D. MONTHLY AMOUNT

24C. BRANCH OF SERVICE
ARMY

NAVY

MARINE CORPS

AIR FORCE

COAST GUARD

SPACE FORCE

NOAA

(If "Yes," explain below (e.g. future Reserve/National Guard retirement, pending
MEB/PEB and also complete Items 24C and 24D)

$

,

25. RETIRED STATUS

.00

RETIRED

PERMANENT DISABILITY
RETIRED LIST

TEMPORARY DISABILITY
RETIRED LIST

USPHS

IMPORTANT INFORMATION ON MILITARY RETIRED PAY (Includes all Uniformed Services Retired Pay):
Submission of this application constitutes a waiver of military retired pay in an amount equal to VA compensation awarded, if you are entitled to both
benefits. Your retired pay may be reduced by the amount of VA compensation awarded. Receipt of the full amount of military retired pay and VA
compensation at the same time may result in an overpayment, which may be subject to collection. If you qualify for concurrent receipt of VA compensation
and military retired pay, the waiver of retired pay will not apply. If you do not want to waive any retired pay to receive VA compensation, you should check
the box in Item 26.
Note that if you check the box in Item 26, you will not receive VA compensation, if granted. If you are currently in receipt of VA compensation and
you check the box in Item 26, your VA compensation will be terminated, if you are also eligible for military retired pay.
IMPORTANT: VA COMPENSATION PAY IS NON-TAXABLE. THEREFORE, VA COMPENSATION PAY MAY BE THE GREATER
BENEFIT.
26. Do NOT pay me VA compensation. I do NOT want to receive VA compensation in lieu of retired pay.
VA FORM 21-526EZ, XXXX

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VETERANS SOCIAL SECURITY NO.

IMPORTANT INFORMATION ON SEPARATION/SEVERANCE PAY:
VA compensation, if granted, may be withheld to recoup any disability severance or separation pay such as involuntary separation pay, voluntary separation
pay, or special separation benefit, you receive from your branch of service. In addition, if you receive a Voluntary Separation Incentive (VSI), your VSI
payments may be reduced if you are awarded VA compensation. Receipt of VA compensation and VSI at the same time may result in an overpayment of VSI,
which may be subject to collection.
27A. HAVE YOU EVER RECEIVED SEPARATION PAY, DISABILITY SEVERANCE PAY, OR ANY OTHER LUMP SUM PAYMENT FROM YOUR BRANCH OF SERVICE?
YES
(If "Yes," complete Items 27B through 27D)
NO
27B. DATE PAYMENT RECEIVED (MM-DD-YYYY) 27C. BRANCH OF SERVICE

27D. AMOUNT RECEIVED

ARMY

NAVY

MARINE CORPS

AIR FORCE

COAST GUARD

SPACE FORCE

NOAA

USPHS

(Provide pre-tax amount)

$

,

.00

IMPORTANT INFORMATION ON INACTIVE DUTY TRAINING PAY:
You may elect to keep the active or inactive duty training pay you received from the military service department. However, to be legally entitled to keep your
training pay, you must waive VA benefits for the number of days equal to the number of days for which you received training pay. In most instances, it will be
to your advantage to waive your VA benefits and keep your training pay.
If you waive VA benefits to receive training pay by checking the box in Item 28, VA will retroactively adjust your VA award to withhold benefits equal to the
total number of training days waived and at the monthly rate in effect for the fiscal year period for which you received training pay. This action may result in
an overpayment of compensation, which may be subject to collection.
IMPORTANT: VA COMPENSATION PAY IS NON-TAXABLE. THEREFORE VA COMPENSATION PAY MAY BE THE GREATER
BENEFIT.
28. Do NOT pay me VA compensation. I do NOT want to receive VA compensation in lieu of training pay.

SECTION VIII: DIRECT DEPOSIT INFORMATION
The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in direct deposit,
provide the information requested below, and attach either a voided personal check or a deposit slip. If you do not have a bank account, please visit https://www.
benefits.va.gov/benefits/banking.asp. This website provides information about the Veterans Benefits Banking Program (VBBP), and a link to banks and credit unions
that may fit your needs. You may also call 1-800-827-1000. 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.
29. I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT (If you check this box skip to Section VIII)
30. ACCOUNT NUMBER (Check only one box below and provide the account number)
CHECKING

Account No.:
31. NAME OF FINANCIAL INSTITUTION (Provide the name of the bank where you

want your direct deposit)

SAVINGS

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

bottom left of your check)

SECTION IX: CLAIM CERTIFICATION AND SIGNATURE
VETERAN/SERVICEMEMBER CERTIFICATION 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. For the limited purpose of providing VA with this information as it may relate to my claim, I waive any privilege that may
apply and would otherwise make the information confidential and not disclosable.
I certify I have received the notice attached to this application titled, Notice to Veteran/Service Member of Evidence Necessary to Substantiate a Claim for
Veterans Disability Compensation and Related Compensation Benefits.
I certify I have enclosed all the information or evidence that will support my claim, to include an identification of relevant records available at a Federal
facility such as a VA medical center; OR, I have no information or evidence to give VA to support my claim; OR, I have checked the box in Item 1, on page
8, indicating I want my claim processed under the standard claim process because I plan to submit additional evidence in support of my claim.
33A. VETERAN/SERVICE MEMBER SIGNATURE (REQUIRED)

33B. DATE SIGNED (MM-DD-YYYY)

SECTION X: WITNESSES TO SIGNATURE
34A. SIGNATURE OF WITNESS (Sign in ink) (Note: Only sign if veteran signed in Item 33A using

34B. PRINTED NAME AND ADDRESS OF WITNESS

35A. SIGNATURE OF WITNESS (Sign in ink) (Note: Only sign if veteran signed in Item 33A using

35B. PRINTED NAME AND ADDRESS OF WITNESS

an "X")

an "X")

VA FORM 21-526EZ, XXXX

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VETERANS SOCIAL SECURITY NO.

SECTION XI: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE
(NOTE: REQUIRED ONLY IF ITEM 33A IS BLANK)
NOTE: An alternate signer signature will not be accepted unless a valid VA Form 21-0972, Alternate Signer Certification, is of record or attached
to this request.

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 a
claimant 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.
36A. ALTERNATE SIGNER SIGNATURE (REQUIRED)

36B. DATE SIGNED (MM-DD-YYYY)

SECTION XII: POWER OF ATTORNEY (POA) SIGNATURE
(NOTE: POA'S CANNOT SIGN FOR AN ORIGINAL CLAIM ONLY)

I certify that the claimant has authorized the undersigned representative to file this claim on behalf of the claimant and that the claimant is aware and accepts
the information provided in this document. I certify that the claimant has authorized the undersigned representative to state that the claimant certifies the truth
and completion of the information contained in this document to the best of claimant's knowledge.
NOTE: A POA's signature will not be accepted unless at the time of submission of this claim a valid VA Form 21-22, Appointment of Veterans Service
Organization as Claimant's Representative, or VA Form 21-22a, Appointment of Individual As Claimant's Representative, indicating the appropriate POA is
of record with VA.
37A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE

37B. 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: 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 Veteran Readiness 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 25 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 21-526EZ, XXXX

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VETERANS SOCIAL SECURITY NO.

SECTION XIII: CLAIM INFORMATION (ADDENDUM)
(Please submit this page with the completed application if you have additional disabilities to add to your claim. If more
space is needed, please make additional copies of this page to submit with your application.)
LIST THE CURRENT DISABILITY(IES) OR SYMPTOMS THAT YOU CLAIM ARE RELATED TO YOUR MILITARY SERVICE AND/OR SERVICE-CONNECTED DISABILITY(If
applicable, identify whether a disability is due to a service-connected disability; confinement as a prisoner of war; exposure to Agent Orange, asbestos, mustard gas, ionizing radiation, or Gulf
War environmental hazards; or a disability for which compensation is payable under 38 U.S.C. 1151)
NOTE: List your claimed conditions below. See the following three examples on guidance on how to complete Section XIII.

EXAMPLES OF DISABILITY(IES)

EXAMPLES OF EXPOSURE
TYPE

EXAMPLES OF HOW THE
DISABILITY(IES) RELATES TO SERVICE

EXAMPLES OF DATES

Example 1. HEARING LOSS

NOISE

HEAVY EQUIPMENT OPERATOR IN SERVICE JULY 1968

Example 2. DIABETES

AGENT ORANGE

SERVICE IN VIETNAM WAR

DECEMBER 1972

INJURED LEFT KNEE WHEN BRACE ON
RIGHT KNEE FAILED

6/11/2008

Example 3. LEFT KNEE, SECONDARY TO RIGHT KNEE

CURRENT DISABILITY(IES)

IF DUE TO EXPOSURE, EVENT, OR
INJURY, PLEASE SPECIFY
(e.g., Agent Orange, radiation,
toxic exposure)

EXPLAIN HOW THE DISABILITY(IES)
RELATES TO THE IN-SERVICE
EVENT/EXPOSURE/INJURY

APPROXIMATE DATE
DISABILITY(IES)
BEGAN OR WORSENED

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
VA FORM 21-526EZ, XXXX

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