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

OMB Control No. 2900-0654
Respondent Burden: 25 Minutes

ANNUAL CERTIFICATION OF VETERAN STATUS AND VETERAN-RELATIVES
Privacy Act Notice: 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, Compensation, Pension, Education and Rehabilitation Records - VA,
published in the Federal Register. Your obligation to respond is mandatory. Giving us your and your veteran relatives’ SSN account information is
mandatory. Any persons, including dependents and beneficiaries, who apply for or receive VA Compensation and Pension benefits are required to
provide their SSN 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 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: We need this information to identify the benefit records VA maintains for you and your relatives in order to insure the security
and confidentiality of the records (5 U.S.C. 552a(e)(10)). 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.whitehouse.gov/omb/library/OMBINV.html#VA. If desired, you can call 1-800-827-1000 and give your comments or ask for mailing
information on where to send your comments.
SECTION I - EMPLOYEE INFORMATION
1. EMPLOYEE’S LAST NAME, FIRST NAME, MIDDLE INITIAL

2. EMPLOYEE’S SOCIAL SECURITY NUMBER

3. EMPLOYEE’S DATE OF BIRTH (MONTH, DAY, YEAR)

4. REGIONAL OFFICE OF EMPLOYMENT

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 on the reverse 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 (Last, First, Middle)

8. YOUR RELATIONSHIP TO VETERAN
SELF
SPOUSE
CHILD

PARENT

9. VETERAN’S MILITARY SERVICE NUMBER
10. VETERAN’S SOCIAL SECURITY NUMBER

11. VETERAN’S DATE OF BIRTH (MONTH, DAY, YEAR)

12. INSURANCE FILE NUMBER (If applicable)
13. CLAIMS FILE NUMBER (If applicable)
14. VA BENEFITS APPLIED FOR (Check all boxes that apply)
NONE

TOTAL OR TOTAL AND PERMANENT
DISABILITY (USGLI)

TOTAL DISABILITY (NSLI)

DISABILITY COMPENSATION

PENSION

RETIREMENT PAY

VOCATIONAL REHABILITATION

EDUCATION OR TRAINING

LOAN GUARANTY

HOSPITAL OR DOMICILIARY CARE

OUTPATIENT TREATMENT

OTHER (Specify below)

VA FORM
JUN 2004

20-0344

SUPERSEDES VA FORM 20-0344, SEP 2001,
WHICH WILL NOT BE USED.

SECTION III - INFORMATION ABOUT YOUR RELATIVES WHO ARE VETERANS AND/OR VA 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 and you do not have access to BIRLS (VA’s
beneficiary information and records locator system), please see your station’s IT Security Officer. Check Item 18 "Additional Information"
and attach a separate sheet if more space is needed.

15. RELATIVE INFORMATION - FIRST
A. RELATIVE’S LAST NAME, FIRST NAME, MIDDLE NAME
B. RELATIONSHIP TO YOU

SPOUSE

CHILD

PARENT

SIBLING

PARENT

SIBLING

PARENT

SIBLING

C.VETERAN’S FULL NAME AS USED IN MILITARY SERVICE
(LAST, FIRST, MIDDLE)
D. VETERAN’S SOCIAL SECURITY NUMBER
E. VETERAN’S MILITARY SERVICE NUMBER
F. INSURANCE FILE NUMBER
G. CLAIMS FILE NUMBER
H. VETERAN’S BIRTHDATE (MONTH, DAY, YEAR)

16. RELATIVE INFORMATION - SECOND
A. RELATIVE’S LAST NAME, FIRST NAME, MIDDLE NAME
B. RELATIONSHIP TO YOU

SPOUSE

CHILD

C.VETERAN’S FULL NAME AS USED IN MILITARY SERVICE
(LAST, FIRST, MIDDLE)
D. VETERAN’S SOCIAL SECURITY NUMBER
E. VETERAN’S MILITARY SERVICE NUMBER
F. INSURANCE FILE NUMBER
G. CLAIMS FILE NUMBER
H. VETERAN’S BIRTHDATE (MONTH, DAY, YEAR)

17. RELATIVE INFORMATION - THIRD
A. RELATIVE’S LAST NAME, FIRST NAME, MIDDLE NAME
B. RELATIONSHIP TO YOU

SPOUSE

CHILD

C.VETERAN’S FULL NAME AS USED IN MILITARY SERVICE
(LAST, FIRST, MIDDLE)
D. VETERAN’S SOCIAL SECURITY NUMBER
E. VETERAN’S MILITARY SERVICE NUMBER
F. INSURANCE FILE NUMBER
G. CLAIMS FILE NUMBER
H. VETERAN’S BIRTHDATE (MONTH, DAY, YEAR)
18. ADDITIONAL INFORMATION

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.
19. SIGNATURE OF EMPLOYEE (Do NOT Print)
20-0344, JUN 2004 (Back)

20. DATE SIGNED