21-527EZ Fully Developed Claim (Express Claim Notice) (Notice to

FULLY DEVELOPED CLAIM

(EXPRESS CLAIM NOTICE)
(Notice to Claimants of Information and Evidence Necessary to Substantiate a Claim for
VA Non-Service Connected Live Pension)
Thank you for participating in the Department of Veterans Affairs (VA) Express Claim Program. VA established the Express
Claim Program to expeditiously process claims certified by the claimant or his/her representative as meeting the Express
Claim criteria.

Express Claim Criteria:
1. For purposes of this notice, your claim must be a rating-related claim for live pension submitted on VA Form 21-527EZ,
Express Pension Claim.
2. You must submit, with your claim, the Express Claim Certification signed and dated by you or your authorized
representative.
3. You must submit with the Express Claim Certification:

• All necessary income and net-worth information.
if any, relevant, private medical treatment records, and an identification of any treatment records from a Federal
• All,
treatment facility such as a VA medical center.
• For Special Monthly Pension claims, a completed VA Form 21-2680, Examination for Housebound Status or

Permanent Need for
Regular Aid and Attendance, or, if claiming Special Monthly Pension based on nursing home attendance, a VA Form,
21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance.

• If claiming dependents, a completed VA Form 21-686c, Declaration of Status of Dependents.
4. You must report for any VA medical examination VA determines necessary to decide your claim.
Note: VA forms are available at www.va.gov/vaforms.
This notice is applicable to your Express Claim for non-service connected live pension. Upon receipt of the Express Claim
Certification, we will expedite your claim under the Express Claim Program. If it is determined that your claim does not meet
the Express Claim criteria we will process your claim through our standard claim process.

WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
To support your claim for nonservice-connected pension, the evidence must show:
1. You met certain minimum requirements regarding active military service during a period of war. Generally, those
requirements involve:

• 90 days of consecutive service, at least one day of which was during a period of war; OR
• 90 days of combined service during at least one period of war;
(Note: If your service began after September 7, 1980, additional length-of-service requirements may apply, typically requiring
two years of continuous service or completion of active-duty obligation)

• OR any length of active military service with a discharge due to a service-connected disability.
2. You are age 65 or older or are permanently and totally disabled. You are considered permanently and totally disabled if
medical evidence shows you are:

• A patient in a nursing home for long-term care; OR
• Receiving Social Security disability benefits; OR
• Unemployable due to a disability reasonably certain to continue throughout your lifetime; OR
• Suffering from a disability that is reasonably certain to continue throughout your lifetime that would make it impossible
for an average person to follow a substantially gainful occupation; OR

• Suffering from a disease or disorder that VA determines causes persons who have that disease or disorder to be
permanently and totally disabled.

3. Your net worth and income do not exceed certain requirements.
VA Form
FEB 2010

21-527EZ

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WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM (Continued)
To support a claim for increased disability pension benefits based on the need for aid and attendance,
the evidence must show:

• You have corrected vision of 5/200 or less in both eyes; OR
• You have contraction of the concentric visual field to 5 degrees or less; OR
• You are a patient in a nursing home due to mental or physical incapacity; OR
require the aid of another person in order to perform personal functions required in everyday
• You
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; OR

are bedridden, in that your disability requires that you remain in bed apart from any
• You
prescribed course of convalescence or treatment.
To support your claim for increased disability pension benefits based on being housebound, the evidence
must show:

• You have a single permanent disability evaluated as 100 percent disabling; AND another disability,
or disabilities, evaluated as 60 percent or more disabling; OR

• You have a single permanent disability evaluated as 100 percent disabling; AND due to such disability,
you are permanently and substantially confined to your immediate premises; OR

were granted pension based on being 65 or older AND have a disability evaluated as at least
• You
60 percent disabling.

HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
Express Claim Process
VA will provide a medical examination for you, or get a medical opinion, if we determine it is necessary to decide your claim.
For this program, VA will only obtain records from VA medical centers. You must obtain all other records and provide them to
VA.
If it is determined that other records exist, and VA needs the records to decide your claim, then your claim will not be
processed as an Express Claim. Your claim will be processed in our standard claim process.
Standard Claim Process
VA is responsible for getting relevant records from any Federal agency that you adequately identify and authorize VA to
obtain. These may include records from the military, VA medical centers (including private facilities where VA authorized
treatment), or the Social Security Administration. VA will provide a medical examination for you, or get a medical opinion, if
we determine it is necessary to decide your claim.
VA will make every reasonable effort to obtain relevant records not held by a Federal agency that you adequately identify and
authorize VA to obtain. These may include records from State or local governments, any privately held evidence and
information you tell us about (such as private doctor or hospital records), or current or former employers.

WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide VA information sufficient to enable VA to obtain all
relevant evidence not in your possession
Express Claim Process
If you provide VA information sufficient to enable VA to obtain relevant VA treatment records and you give VA all other
records relevant to your claim, the claim may be decided under the Express Claim Process. This means that, if you are
aware of relevant records that are not in your possession, you should obtain them and provide them to VA in order to
participate in the Express Claim Process.
Standard Claim Process
If you know of evidence not in your possession and want VA to try to get it for you, you must give VA enough information
about the 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.

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WHEN YOU SHOULD SEND WHAT WE NEED
Express Claim Process
Send the information and evidence with the Express Claim Certification. If we decide your claim before one year from the
date we receive this claim, you will still have the remainder of the one-year period to submit additional information or
evidence necessary to support your claim.
Standard Claim Process
We strongly encourage you to send any information or evidence as soon as you can. If we do not hear from you, we may
make a decision on your claim after 30 days. However, you have up to one year from the date we receive this claim to submit
the information and evidence necessary to support your claim. If we decide your claim before one year from the date we
receive this claim, you will still have the remainder of the one-year period to submit additional information or evidence
necessary to support your claim.

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OMB Control No. 2900-xxxx
Respondent Burden: 25 minutes

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

FULLY DEVELOPED CLAIM
(EXPRESS PENSION CLAIM)

IMPORTANT: Please read the Privacy Act and Respondent Burden on the back before completing the form.
This claim must be submitted along with the attached, "Express Claim Certification."

SECTION I: TO BE COMPLETED BY VETERAN
1. VETERAN'S NAME (Last, first, middle)

4. SEX
MALE

3. DATE OF BIRTH (MM,DD,YYYY)

2. SOCIAL SECURITY NUMBER

5. HAVE YOU EVER FILED A CLAIM WITH VA?
YES
NO
(If "Yes," provide your file number in Item 6)

FEMALE

6. VA FILE NUMBER

7B. TELEPHONE NUMBERS (Include Area Code)

7A. CURRENT ADDRESS
Street address, rural route, or P.O. Box
City

State

Daytime

Apt. number
ZIP Code

Evening

Country

8A. PREFERRED E-MAIL ADDRESS (If applicable)

Cell phone
8B. ALTERNATE E-MAIL ADDRESS (If applicable)

9. WHAT DISABILITY(IES) PREVENTS YOU FROM WORKING AND DATE DISABILITY(IES) BEGAN
A. DISABILITY(IES)

B. DATE BEGAN

10. LIST VA MEDICAL CENTERS WHERE YOU RECEIVED TREATMENT FOR YOUR CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES
10B. DATE(S) OF TREATMENT

A. NAME AND LOCATION OF VA MEDICAL CENTER

11A. DID YOU SERVE UNDER ANOTHER NAME?

SECTION II: SERVICE INFORMATION

11B. PLEASE LIST OTHER NAME(S) YOU SERVED UNDER

YES (If "Yes," go to Item 11B)
NO (If "No," go to Item 12A)
12A. I ENTERED MY MOST RECENT PERIOD OF 12B. BRANCH OF SERVICE
ACTIVE SERVICE ON (MM,DD,YYYY)
12D.DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?
YES
NO

12C. RELEASE DATE OR ANTICIPATED DATE
OF RELEASE FROM ACTIVE DUTY

12E. PLACE OF SEPARATION
13B. DATE OF ACTIVATION (MM,DD,YYYY)

13A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
AUTHORITY OF TITLE 10, U.S.C. (National Guard)?
NO
YES
(If "Yes," provide date of activation in Item 13B)
14A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?

15B. I PREVIOUSLY ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)

15A. DO YOU HAVE ADDITIONAL PERIODS OF ACTIVE SERVICE?
YES (If "Yes," go to Item 15B)
NO

(If "No," go to Item 16A)

16A. DID YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE/RETIRED PAY?

YES

14B. WHAT IS THE TELEPHONE
NUMBER OF YOUR CURRENT
UNIT? (Include Area Code)

NO

(If "Yes,"complete Items 16B and 16C)

16B. LIST AMOUNT (If known)

16C. LIST TYPE (If known)

$

SECTION III: WORK HISTORY
IN THE TABLE BELOW, TELL US ABOUT ALL OF YOUR EMPLOYMENT, INCLUDING SELF-EMPLOYMENT, FOR ONE YEAR BEFORE YOU
BECAME DISABLED TO THE PRESENT.
17A. WHAT WAS THE NAME AND
ADDRESS OF YOUR EMPLOYER?

17B. WHAT WAS YOUR
JOB TITLE?

17C. WHEN DID
YOUR WORK
BEGIN?

17D. WHEN DID
YOUR WORK
END?

17E. HOW MANY
DAYS WERE LOST
DUE TO DISABILITY?

17F. WHAT WERE YOUR
TOTAL ANNUAL
EARNINGS?

$
$
VA FORM
FEB 2010

21-527EZ

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SECTION IV: INCOME VERIFICATION
18A. MONTHLY INCOME (GROSS MONTHLY AMOUNTS (If no income was received from a particular source, write "0" or "none." DO NOT LEAVE BLANK)

SOURCE

VETERAN

SOCIAL SECURITY

SPOUSE

$

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
MILITARY RETIREMENT
OTHER (Show source below)
18B. ANNUAL INCOME (If no income was received from a particular source, write "0" or "none." DO NOT LEAVE BLANK)

NOTE: Report last calendar year (January through December) income in the left-hand column and current year income in the
right-hand column.
SOURCE

SPOUSE

VETERAN

GROSS WAGES FROM ALL
EMPLOYMENT

$

$

TOTAL INTEREST AND DIVIDENDS
ALL OTHER (Show source below)

ALL OTHER (Show source below)

18C. NET WORTH (If no income was received from a particular source, write "0" or "none." DO NOT LEAVE BLANK)

SOURCE

VETERAN

CASH/NON-INTEREST-BEARING BANK
ACCOUNTS

$

SPOUSE

$

INTEREST-BEARING BANK ACCOUNTS
IRA'S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY

SECTION V: MEDICAL, LEGAL OR OTHER UNREIMBURSED EXPENSES
Family medical expenses and certain other expenses actually paid by you may be deductible from your income. Show the amount of unreimbursed medical expenses,
including the Medicare deduction, you paid for yourself or relatives who are members of your household. Also, show unreimbursed last illness and burial expenses and
educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are unreimbursed amounts paid by you for the last illness and burial of a spouse
or child at any time prior to the end of the year following the year of death. Educational or vocational rehabilitation expenses are amounts paid for courses of education,
including tuition, fees, and materials. Show medical, legal or other expenses you paid because of a disability for which civilian disability benefits have been awarded. When
determining your income, we may be able to deduct them from the disability benefits for the year in which the expenses are paid. Do not include any expenses for which you
were reimbursed. If more space is needed continue on page 6 or attach a separate sheet.

19A. Amount paid by you

VA FORM 21-527EZ, FEB 2010

19B. Date paid

19C. Purpose

(Doctor's fees, hospital
charges, attorney fees, etc.)

19D. Paid to

(Name of doctor, hospital,
pharmacy, etc.)

19E. Disability or relationship
of person for whom
expenses paid

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SECTION V: MEDICAL, LEGAL OR OTHER UNREIMBURSED EXPENSES (Continued)
20A. Amount paid by you

20B. Date paid

20C. Purpose

(Doctor's fees, hospital
charges, attorney fees, etc.)

20D. Paid to

(Name of doctor, hospital,
pharmacy, etc.)

20E. Disability or relationship
of person for whom
expenses paid

SECTION VI: DIRECT DEPOSIT INFORMATION
Generally, all Federal payments are required to be made by electronic funds transfer (EFT), also called Direct Deposit. Please attach a voided personal
check or deposit slip or provide the information requested below in Items 21, 22 and 23 to enroll in Direct Deposit. If you do not have a bank account, we
will give you a waiver from Direct Deposit, just check the box below in Item 21. The Treasury Department is working to make bank accounts available in
such situations. Once these accounts are available, you will be able to decide whether you wish to sign-up for one of the accounts or continue to receive
a paper check. You can also request a waiver if you have other circumstances that you feel would cause a hardship if you enrolled in Direct Deposit.
You can write to: Department of Veterans Affairs, 125 S. Main Street, Suite B, Muskogee, OK 74401-7004, and give us a brief description of why you do
not wish to participate in Direct Deposit.
21. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)
CHECKING

SAVINGS

22. NAME OF FINANCIAL INSTITUTION (Please provide the name of

the bank where you want your direct deposit)

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT
WITH A FINANCIAL INSTITUTION OR CERTIFIED
PAYMENT AGENT
23. ROUTING OR TRANSIT NUMBER (The first nine numbers located

at the bottom left of your check)

SECTION VII: CERTIFICATIONS 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 except protected health information, and I waive any
privilege which makes the information confidential.
24A. YOUR SIGNATURE (Do NOT print)

24B. DATE SIGNED

SECTION VIII: WITNESSES TO SIGNATURE
25A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

25B. PRINTED NAME AND ADDRESS OF WITNESS

26A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

26B. PRINTED NAME AND ADDRESS OF WITNESS

PRIVACY ACT NOTICE: The form will be used to determine allowance to pension 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 Vocational Rehabilitation 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 pension. 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.VA.EPA.html#VA. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-527EZ, FEB 2010

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EXPRESS CLAIM CERTIFICATION

Name

Date

Claim Number

Social Security Number

Your signature on this response will not affect:

•

Whether or not you are entitled to VA benefits;

•

The amount of benefits to which you may be entitled;

•

The assistance VA will provide you in obtaining evidence to support your claim; or

•

The date any benefits will begin if your claim is granted.

I have enclosed all the information or evidence that will support my claim to include identifying records from Federal treating
facilities, or I have no information or evidence to give VA to support my claim. Please decide my claim as soon as possible.

Claimant/Representative's Signature

VA FORM 21-527EZ, FEB 2010

Date

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