20-0344 Annual Certification of Veteran Status and Veteran-Relat

OMB Control No. 2900-0654
Respondent Burden: 25 Minutes
Expiration Date: XX/XX/20XX

ANNUAL CERTIFICATION OF VETERAN STATUS AND VETERAN-RELATIVES
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to provide information that
identifies the benefit records VA maintains for you and your relatives to ensure the security and confidentiality of the records. For more information,
contact us online through Ask VA: https://www.va.gov/contact-us, Or call us toll-free at 800-827-1000 (TTY: 711).
SECTION I - EMPLOYEE INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to help
expedite processing of the form.
1. EMPLOYEE'S NAME (First, Middle Initial, Last)

2. EMPLOYEE'S SOCIAL SECURITY NUMBER

3. EMPLOYEE'S DATE OF BIRTH (MM/DD/YYYY)

4. STATION OF EMPLOYMENT (Specify which administration or staff office you are

employed by and note your facility name or number in the space provided)
VBA

VHA

NCA

Specify:
5. HAVE YOU EVER APPLIED FOR OR RECEIVED BENEFITS FROM THE DEPARTMENT OF VETERANS AFFAIRS? (Either as a veteran or a

veteran's dependent)
YES

NO

6. HAVE YOU EVER SERVED ON ACTIVE DUTY IN THE U.S. MILITARY?
YES

NO

NOTE: If your answer is "no" to both Items 5 and 6 above, skip Section II and proceed to Section III to complete the remainder of the form. If your
answer is "yes" to either or both items, please complete the entire form including Items 7 through 14 below. If you are a veteran, provide the
information requested in Items 7 through 14 relative to your military status and VA claims records. If you are a veteran's dependent, provide the
requested information for the veteran on whom your benefits eligibility is based.
SECTION II - VETERAN EMPLOYEE/VETERAN'S DEPENDENT INFORMATION
7. VETERAN'S FULL NAME AS USED IN MILITARY SERVICE (First, Middle Initial, Last)
8. YOUR RELATIONSHIP TO VETERAN
SELF

SPOUSE

CHILD

9. VETERAN'S MILITARY SERVICE NUMBER
PARENT

10. VETERAN'S SOCIAL SECURITY NUMBER

11. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

12. INSURANCE FILE NUMBER (If applicable)

13. CLAIMS FILE NUMBER (If applicable)

14. VA BENEFITS APPLIED FOR (Check all boxes that apply)
NONE

PENSION

TOTAL DISABILITY (NSLI)

DISABILITY COMPENSATION

EDUCATION OR TRAINING

RETIREMENT PAY

VETERAN READINESS AND EMPLOYMENT

OUTPATIENT TREATMENT

LOAN GUARANTY

HOSPITAL OR DOMICILIARY CARE

TOTAL OR TOTAL AND PERMANENT DISABILITY (USGLI)

OTHER (Specify):

VA FORM
XXX XXXX

20-0344

SUPERSEDES VA FORM 20-0344, JUN 2021.

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SECTION III - INFORMATION ABOUT YOUR RELATIVES WHO ARE VETERANS AND/OR BENEFICIARIES
NOTE: List all relatives (spouse, child, parent, sibling) who are veterans or who have applied for or are receiving benefits as a veteran's dependent.
If assistance is needed in obtaining military service numbers and/or claims numbers, please speak to your immediate supervisor. Check Item 18
"Additional Information" and attach a separate sheet if more space is needed.
15. RELATIVE INFORMATION - FIRST
A. RELATIVE'S NAME (First, Middle Initial, Last)
B. RELATIONSHIP TO YOU

SPOUSE

CHILD

PARENT

SIBLING

C. VETERAN'S FULL NAME AS USED IN MILITARY SERVICE

(First, Middle Initial, Last)

D. VETERAN'S SOCIAL SECURITY NUMBER
E. VETERAN'S MILITARY SERVICE NUMBER (If applicable)
F. INSURANCE FILE NUMBER
G. CLAIMS FILE NUMBER
H. VETERAN'S BIRTHDATE (MM/DD/YYYY)

16. RELATIVE INFORMATION - SECOND
A. RELATIVE'S NAME (First, Middle Initial, Last)
B. RELATIONSHIP TO YOU

SPOUSE

CHILD

PARENT

SIBLING

PARENT

SIBLING

C. VETERAN'S FULL NAME AS USED IN MILITARY SERVICE

(First, Middle Initial, Last)

D. VETERAN'S SOCIAL SECURITY NUMBER
E. VETERAN'S MILITARY SERVICE NUMBER (If applicable)
F. INSURANCE FILE NUMBER
G. CLAIMS FILE NUMBER
H. VETERAN'S BIRTHDATE (MM/DD/YYYY)

17. RELATIVE INFORMATION - THIRD
A. RELATIVE'S NAME (First, Middle Initial, Last)
B. RELATIONSHIP TO YOU

SPOUSE

CHILD

C. VETERAN'S FULL NAME AS USED IN MILITARY SERVICE

(First, Middle Initial, Last)

D. VETERAN'S SOCIAL SECURITY NUMBER
E. VETERAN'S MILITARY SERVICE NUMBER (If applicable)
F. INSURANCE FILE NUMBER
G. CLAIMS FILE NUMBER
H. VETERAN'S BIRTHDATE (MM/DD/YYYY)

Please check if additional relatives are identified on an attachment to this form.
I CERTIFY THAT the above information is correct and complete to the best of my knowledge and belief.
19. SIGNATURE OF EMPLOYEE (Required)

20. DATE SIGNED (MM/DD/YYYY)

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 Veteran Readiness and Employment Records - VA, published in the
Federal Register. This information is used to ensure your records and the records of any identified relatives who work for the VA obtain an additional level of security assisting in the
prevention of improper disclosure of personal information. Your obligation to respond is mandatory. 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 responses you submit are considered confidential (38 U.S.C. 5701).
Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0654, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 25 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0654 in any correspondence. Do not send your completed VA Form 20-0344 to this email address.

VA FORM 20-0344, XXX XXXX

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