Form 21-4169 Supplement to VA Forms 21-526, 21-534, and 21-535 (For P

OMB Approved No. 2900-0094
Respondent Burden: 15 minutes

VA DATE STAMP
DO NOT WRITE IN THIS SPACE

SUPPLEMENT TO VA FORMS 21-526, 21-534, AND 21-535
(For Philippine Claims)
INSTRUCTIONS: All questions must be answered fully, clearly and correctly. If answer is unknown, write
"unknown." If additional space is needed, use Item 24 "Remarks" and identify your answers by the item
numbers to which they apply.
1. LAST NAME -FIRST NAME- MIDDLE NAME OF VETERAN

2. VA FILE NUMBER

3A. LAST NAME - FIRST NAME - MIDDLE NAME OF CLAIMANT
(If other than Veteran)

3B. ADDRESS OF CLAIMANT

3C. RELATIONSHIP TO VETERAN (Self, wife, child, mother, father)

3D. FULL MAIDEN NAME OF CLAIMANT’S MOTHER

3E. LAST NAME - FIRST NAME - MIDDLE NAME OF CLAIMANT’S FATHER

PART I - SERVICE INFORMATION OF VETERAN
NOTE: List each period of active service. Show all service numbers, if known.
4. BRANCH OF SERVICE IN WHICH VETERAN SERVED (Check if service is other than that shown in Items 6A-6G or 7A-7G)
ARMY
NAVY
AIR FORCE
5A. ENTERED SERVICE
DATE

MARINE CORPS
COAST GUARD
OTHER (Specify)
5B. SERVICE NUMBER
5C. SEPARATED FROM SERVICE

PLACE

DATE

5D. GRADE AND ORGANIZATION

PLACE

PHILIPPINE ARMY
6A. ENTERED SERVICE
DATE

6B. SERVICE NUMBER

PLACE

6C. SEPARATED FROM SERVICE
DATE

PLACE

7D.
7E.
DIVISION REGIMENT

7F.
COMPANY

7G.
RANK

7D.
7E.
DIVISION REGIMENT

7F.
COMPANY

7G.
RANK

GUERILLA ORGANIZATION
7A. ENTERED SERVICE
DATE

7B. SERVICE NUMBER

7C. NAME OF ORGANIZATION

PLACE

NOTE: Complete Items 8A through 12D only, if VA Form 21-526 is submitted. Skip to Item 13, if VA Form 21-534 or 21-535 is submitted.
8A. WERE YOU GIVEN A PHYSICAL EXAMINATION WHEN YOU ENLISTED AND/OR RETURNED TO MILITARY CONTROL?
YES
NO (If "Yes," explain in Items 8B and 8C) (If "No," skip to Item 9A)
8C. PLACE OF EXAMINATION (Address)
9A. AT THE TIME OF YOUR SEPARATION FROM SERVICE WERE
THERE ANY COURT MARTIAL OR OTHER MILITARY CHARGES?

8B. DATE EXAMINED

9B. MILITARY CHARGES

(If "Yes," explain in Item 9B)
YES
NO
10A. DID YOU HAVE A COMBAT WOUND OR INJURY DURING ACTIVE SERVICE IN
10B. AFFIDAVITS FROM COMRADES MUST BE FURNISHED (Check one)
WORLD WAR II?
AFFIDAVITS
AFFIDAVITS WILL BE FURNISHED
YES
NO (If "Yes," complete Item 10B)
ATTACHED
AT A LATER DATE
11. DO YOU HAVE ANY EVIDENCE TO PROVE YOUR MILITARY SERVICE AND/OR ANY CLINICAL OR MEDICAL RECORDS COVERING THE DISABILITIES FOR
WHICH YOU CLAIM COMPENSATION? (Check applicable box)
RECORDS ARE ATTACHED
RECORDS WILL BE FURNISHED AT A LATER DATE
NO RECORDS AVAILABLE (Explain here)
12A. ARE YOU NOW RECEIVING
12C. DISABILITY FOR WHICH YOU WERE TREATED
12B. DATE
HOSPITALIZATION OR
IN THIS INSTITUTION
ENTERED
DOMICILIARY CARE FROM THE
INSTITUTION
PHILIPPINE GOVERNMENT OR
ANY OF ITS SUBDIVISIONS?
(If "Yes," complete
Items
YES
NO 12B, 12C & 12D)
VA FORM
EXISTING STOCKS OF VA FORM 21-4169, MAY 1999,
OCT 2004
WILL BE USED.

21-4169

12D. NAME AND ADDRESS OF INSTITUTION

PART II - ACTIVITIES OF CLAIMANT DURING JAPANESE OCCUPATION
13. WHERE DID YOU LIVE DURING THE FOLLOWING YEARS:
(State the province, municipality, barrio, and street)

14. NAMES AND ADDRESSES OF YOUR EMPLOYERS FOR THE FOLLOWING
YEARS: (State if self-employed or unemployed)

1942

1942

1943

1943

1944

1944

1945

1945

15A. WERE YOU A MEMBER OF ANY PRO-JAPANESE, PRO-GERMAN OR ANTI-AMERICAN-FILIPINO ORGANIZATIONS?
(If "Yes," complete Items 15B and 16. If "NO," skip to Item 17.)
NO
YES
15B. ORGANIZATIONS (Check all boxes that apply)
MAKAPILI

PAMPAR

MATSUYAMA
BUTAI

PEACE
ARMY

OTHER PRO-JAPANESE OR PRO-GERMAN OR
ANTI-AMERICAN-FILIPINO ORGANIZATIONS
(Specify each below)

SAKDAL
GANAP

SHIN
NICHI TAI

SAKDAL

JAPANESE-FILIPINO
BROTHERHOOD ASSN.

MORISITA
BUTAI

HIRATA-TAI

GANAP

STANDING ARMY OF
THE PHILIPPINES

NEW LEADERS
YOIN
NEW UNITY
ASSOCIATION
16. GIVE FACTS, CIRCUMSTANCES, AND REASON FOR JOINING THE ORGANIZATION(S) CHECKED IN ITEM 15B (Give details)

17A. DID YOU BELONG TO ANY OF THE ORGANIZATIONS LISTED IN ITEM 17B
DURING THE JAPANESE OCCUPATION?

17B. ORGANIZATIONS (Check all boxes that apply)

BUREAU OF CONSTABULARY
MANILA DEFENSE CORPS
(If "YES," complete Item 17B)
NO
YES
18. IF YOU WERE A MEMBER OF ANY OF THE ORGANIZATIONS LISTED IN ITEM 17B, COMPLETE ITEMS 18A THROUGH 18F.
A. DID YOU AT ANY TIME OR IN ANY WAY ASSIST ANY GUERILLA UNITS OR
B. GIVE DETAILS
THE RESISTANCE MOVEMENT?

MUNICIPAL POLICE FORCE
PHILIPPINE CONSTABULARY

(If "YES," complete Item 18B)
NO
YES
C. GIVE THE NAMES OF PERSONS OR UNITS YOU ASSISTED

D. WERE YOUR SERVICES RECOGNIZED BY THE GUERILLAS OR LEADERS
OF THE RESISTANCE MOVEMENT?

E. STATE HOW AND BY WHOM

(If "YES," complete
YES
NO
Item 18E)
F. DURING YOUR SERVICE IN THE ORGANIZATION DID YOU EVER DESERT OR LEAVE YOUR JOB?
(If "YES," check one
YES
NO
of the following)
19A. DURING YOUR SERVICE DID YOU EVER
ATTEMPT TO FIND OTHER WORK?

YES

NO

(If "YES," complete
Item 19B)

YOU WERE REGARDED
AS AWOL
19B. WHY NOT?

YOU RETURNED OF YOUR
OWN FREE WILL

YOU WERE PUNISHED
FOR LEAVING

20. DID YOU EVER TAKE ANY OATH OR AFFIRMATION, FORMALLY OR INFORMALLY, TO SUPPORT OR COOPERATE WITH THE JAPANESE OR GERMAN
GOVERNMENTS, OR ANY FOREIGN GOVERNMENT, AGAINST THE UNITED STATES AND/OR ITS ALLIES; OR DID YOU EVER MAKE ANY FORMAL OR
INFORMAL RENUNCIATION OF YOUR ALLEGIANCE TO THE UNITED STATES?
(If "YES," give the facts, circumstances and nature of the oath below)

YES

NO

21A. AS A RESULT OF YOUR ACTIVITIES, WERE YOU (or any of your immediate family) EVER ARRESTED OR WERE ANY CHARGES FILED AGAINST YOU (or them)
IN THE PEOPLE’S COURT, LOYALTY BOARD OF THE PHILIPPINE ARMY, LOYALTY BOARD OF THE U.S. ARMY, OR ANY OTHER AGENCY FOR HELPING
OR AIDING THE JAPANESE ARMED FORCES OR THE JAPANESE PUPPET GOVERNMENT, OR ANY OTHER ENEMY OF THE UNITED STATES?
YES
NO (If "YES," complete Items 21B through 21G). (If "No," skip to Item 22A).
21B. NAME OF ACCUSING AGENCY
21C. NAME OF PERSON ACCUSED

21D. DATE ACCUSED

21E. PLACE

21F. NATURE OF THE CHARGE

21G. OUTCOME OF THE CASE

PART III - MISCELLANEOUS INFORMATION
22A. HAVE YOU EVER APPLIED FOR ANY BENEFITS FROM THE PHILIPPINE GOVERNMENT?
YES

NO

(If "YES," check Item 22B and/or Item 22C and complete information requested). (If "No," skip to Item 23).

PHILIPPINE GOVERNMENT BENEFITS
22B.

AMOUNT OF SETTLEMENT

DATE

CLAIM NO.

OFFICE WITH WHICH FILED

AMOUNT OF PENSION

DATE

CLAIM NO.

OFFICE WITH WHICH FILED

ARREARS IN PAY (back pay)
FROM PHIL COM
22C.
PENSION WITH PHILIPPINE
VETERAN’S BOARD

23. IF CLAIMANT IS THE WIDOW OF THE VETERAN, FURNISH THE FOLLOWING INFORMATION:
A. HAVE YOU LIVED AS THE WIFE OF ANY MAN SINCE THE DEATH OF THE VETERAN?
YES
(If "YES," Complete Items 23B through 23F). (If "No," skip to Item 24).
NO
B. FULL NAME OF PERSON WITH WHOM YOU LIVED
C. ADDRESS OF PERSON WITH WHOM YOU LIVED

D. BEGINNING DATE OF THIS RELATIONSHIP (Give month, day and year)

E. PLACE OF RESIDENCE DURING EXISTENCE OF THIS RELATIONSHIP

F. WERE ANY CHILDREN BORN TO THIS RELATIONSHIP?

YES

NO

(If "YES," furnish the following information)
NAME OF CHILD

DATE OF BIRTH

PLACE OF BIRTH

24. REMARKS

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 required to obtain or retain benefits. The
requested information is considered relevant and necessary to determine maximum benefits 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 in order to determine continued eligibility for REPS benefits (38 U.S.C. 5101 (a)). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 15 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.

25.CERTIFICATION
I HEREBY CERTIFY THAT I
(have read)
(have had read to me) all the questions and answers in this application, that the answers to all the
above questions are true and complete to the best of my knowledge and belief and that I have submitted all available information and evidence in support of this
application, with full knowledge of the penalty provided for making a false statement as to a material fact in such application and knowing that if any statement is false,
I may forfeit all rights to benefits from the United States Department of Veterans Affairs.
SIGNATURE OF CLAIMANT (If claimant can write, then he or she must sign the name. If claimant cannot write then affix thumbprint
which must be witnessed by two persons who can write)

DATE

WITNESS TO THUMBPRINT
PRINT NAME (First-Middle-Last) AND ADDRESS OF WITNESS

SIGNATURE OF WITNESS

DATE

PRINT NAME (First-Middle-Last) AND ADDRESS OF WITNESS

SIGNATURE OF WITNESS

DATE