Form 21-8940 Veteran's Application for Increased Compensation Based o

OMB Approved No. 2900-0404
Respondent Burden: 45 minutes

VETERAN'S APPLICATION FOR INCREASED
COMPENSATION BASED ON UNEMPLOYABILITY
NOTE: This is a claim for compensation benefits based on unemployability. When you complete this form you are claiming total disability because of a serviceconnected disability(ies) which has/have prevented you from securing or following any substantially gainful occupation. Answer all questions fully and accurately.
Social Security Benefits: Individuals who have a disability and meet medical criteria may qualify for Social Security or Supplemental Security Income disability benefits.
If you would like more information about Social Security benefits, contact your nearest Social Security Administration (SSA) office. You can locate the address of the
nearest SSA office in your telephone book blue pages under "United States Government, Social Security Administration" or call 1-800-772-1213 (Hearing Impaired TDD
line 1-800-325-0778.). You may also contact SSA by Internet at http://www.ssa.gov/.
1. VA FILE NUMBER

2. VETERAN'S SOCIAL SECURITY NUMBER

3. DATE OF BIRTH

5. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)

4. NAME OF VETERAN (First, Middle, Last) (Type or Print)

SECTION I - DISABILITY AND MEDICAL TREATMENT
6. WHAT SERVICE-CONNECTED DISABILITY
PREVENTS YOU FROM SECURING OR FOLLOWING
ANY SUBSTANTIALLY GAINFUL OCCUPATION?

7. HAVE YOU BEEN UNDER A DOCTOR'S CARE
AND/OR HOSPITALIZED WITHIN THE PAST
12 MONTHS?

8. DATE(S) OF TREATMENT BY DOCTOR(S)

9. NAME AND ADDRESS OF DOCTOR(S)

10. NAME AND ADDRESS OF HOSPITAL

11. DATE(S) OF HOSPITALIZATION

12. DATE YOUR DISABILITY AFFECTED FULL-TIME
EMPLOYMENT

13. DATE YOU LAST WORKED FULL-TIME

14. DATE YOU BECAME TOO DISABLED TO WORK

15A. WHAT IS THE MOST YOU EVER EARNED IN
ONE YEAR?

15B. WHAT YEAR?

15C. OCCUPATION DURING THAT YEAR

SECTION II - EMPLOYMENT STATEMENT

$
16. LIST ALL YOUR EMPLOYMENT INCLUDING SELF-EMPLOYMENT FOR THE LAST FIVE YEARS YOU WORKED
A. NAME AND ADDRESS OF EMPLOYER

B. TYPE OF
WORK

D. DATES OF EMPLOYMENT

C. HOURS
PER WEEK

G. INDICATE YOUR TOTAL EARNED INCOME FOR THE PAST 12 MONTHS

FROM

TO

E. TIME LOST
FROM ILLNESS

F. HIGHEST GROSS
EARNINGS
PER MONTH

H. IF PRESENTLY EMPLOYED, INDICATE YOUR CURRENT MONTHLY EARNED
INCOME

$

$
17. DID YOU LEAVE YOUR LAST JOB/SELF-EMPLOYMENT
BECAUSE OF YOUR DISABILITY?
(If "Yes," give the facts in Item 24)
NO
YES

18. DO YOU RECEIVE/EXPECT TO RECEIVE
DISABILITY RETIREMENT BENEFITS?
YES

19. DO YOU RECEIVE/EXPECT TO RECEIVE
WORKERS COMPENSATION BENEFITS?

NO

YES

NO

20. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?
YES

NO

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

A. NAME AND ADDRESS OF EMPLOYER

VA FORM
OCT 2004

21-8940

B. TYPE OF WORK

SUPERSEDES VA FORM 21-8940, MAR 2000,
WHICH WILL NOT BE USED

C. DATE APPLIED

SECTION III - SCHOOLING AND OTHER TRAINING
21. EDUCATION (Check highest year completed)

GRADE SCHOOL

1

2

3

4

5

6

7

8 HIGH SCHOOL

1

2

3

4

COLLEGE

1

2

3

4

22A. DID YOU HAVE ANY OTHER EDUCATION AND TRAINING BEFORE YOU WERE TOO DISABLED TO WORK?
YES

NO

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

22C. DATES OF TRAINING

22B. TYPE OF EDUCATION OR TRAINING

BEGINNING

COMPLETION

23A. HAVE YOU HAD ANY EDUCATION AND TRAINING SINCE YOU BECAME TOO DISABLED TO WORK?
YES

NO

(If "Yes," complete Items 23B and 23C)

23C. DATES OF TRAINING

23B. TYPE OF EDUCATION OR TRAINING

BEGINNING

COMPLETION

24. REMARKS

SECTION IV - AUTHORIZATION, CERTIFICATION, AND SIGNATURE
AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the 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 except protected health information, and I waive any privilege which makes
the information confidential.
CERTIFICATION OF STATEMENTS: I CERTIFY THAT as a result of my service-connected disabilities, I am unable to secure or follow any substantially gainful
occupation and that the statements in this application are true and complete to the best of my knowledge and belief . I understand that these statements will be considered
in determining my eligibility for VA benefits based on unemployability because of service-connected disability.
I UNDERSTAND THAT IF I AM GRANTED SERVICE-CONNECTED TOTAL DISABILITY BENEFITS BASED ON MY UNEMPLOYABILITY, I MUST
IMMEDIATELY INFORM VA IF I RETURN TO WORK. I ALSO UNDERSTAND THAT TOTAL DISABILITY BENEFITS PAID TO ME AFTER I BEGIN
WORK MAY BE CONSIDERED AN OVERPAYMENT REQUIRING REPAYMENT TO VA.
25. SIGNATURE OF CLAIMANT

26. DATE SIGNED

27. TELEPHONE NUMBER(S) (Include Area Code)
A. DAYTIME

B. NIGHTTIME

WITNESS TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK. NOTE: Signature made by mark must be witnessed by two persons to whom the person
making the statement is personally known and the signature and address of such witnesses must be shown below.
28A. SIGNATURE OF WITNESS

28B. ADDRESS OF WITNESS

29A. SIGNATURE OF WITNESS

29B. ADDRESS OF WITNESS

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 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 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 required 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). 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 provided under the law. 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 determine eligibility for individual unemployment (38 U.S.C. 1163). Title 38, United States Code, allows us to
ask for this information. We estimate that you will need an average of 45 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 to get information on where to send comments or suggestions about this form.