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

3B. ADDRESS OF CLAIMANT

(If other than Veteran)

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

DATE

DATE

6B. SERVICE NUMBER

DATE

PLACE

PHILIPPINE ARMY

6C. SEPARATED FROM SERVICE

PLACE

7A. ENTERED SERVICE

5D. GRADE AND ORGANIZATION

5C. SEPARATED FROM SERVICE

PLACE

6A. ENTERED SERVICE

OTHER (Specify)

COAST GUARD

5B. SERVICE NUMBER

PLACE

DATE

7D.
7E.
DIVISION REGIMENT

7F.
COMPANY

7G.
RANK

7D.
7E.
DIVISION REGIMENT

7F.
COMPANY

7G.
RANK

GUERILLA ORGANIZATION

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

8C. PLACE OF EXAMINATION (Address)

9A. AT THE TIME OF YOUR SEPARATION FROM SERVICE WERE
THERE ANY COURT MARTIAL OR OTHER MILITARY CHARGES?

YES

NO

(If "Yes," complete Item 10B)

9B. MILITARY CHARGES

NO (If "Yes," explain in Item 9B)

10A. DID YOU HAVE A COMBAT WOUND OR INJURY DURING ACTIVE SERVICE IN
WORLD WAR II?
YES

8B. DATE EXAMINED

(If "Yes," explain in Items 8B and 8C) (If "No," skip to Item 9A)

10B. AFFIDAVITS FROM COMRADES MUST BE FURNISHED (Check one)
AFFIDAVITS
ATTACHED

AFFIDAVITS WILL BE FURNISHED
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
12B. DATE
ENTERED
HOSPITALIZATION OR
INSTITUTION
DOMICILIARY CARE FROM THE
PHILIPPINE GOVERNMENT OR
ANY OF ITS SUBDIVISIONS?
YES
VA FORM
AUG 2011

12C. DISABILITY FOR WHICH YOU WERE TREATED
IN THIS INSTITUTION

(If "Yes,"
complete Items

NO 12B, 12C & 12D)

21-4169

EXISTING STOCKS OF VA FORM 21-4169, OCT 2004,
WILL BE USED.

12D. NAME AND ADDRESS OF INSTITUTION

PART II - ACTIVITIES OF CLAIMANT DURING JAPANESE OCCUPATION
14. NAMES AND ADDRESSES OF YOUR EMPLOYERS FOR THE FOLLOWING
YEARS: (State if self-employed or unemployed)

13. WHERE DID YOU LIVE DURING THE FOLLOWING YEARS:

(State the province, municipality, barrio, and street)

1942

1942

1943

1943

1944

1944

1945

1945

15A. WERE YOU A MEMBER OF ANY PRO-JAPANESE, PRO-GERMAN OR ANTI-AMERICAN-FILIPINO ORGANIZATIONS?
YES

NO

(If "Yes," complete Items 15B and 16. If "NO," skip to Item 17.)

15B. ORGANIZATIONS (Check all boxes that apply)
MAKAPILI
PAMPAR
MATSUYAMA
BUTAI

OTHER PRO-JAPANESE OR PRO-GERMAN OR
ANTI-AMERICAN-FILIPINO ORGANIZATIONS

PEACE
ARMY

SAKDAL
GANAP

SHIN
NICHI TAI

SAKDAL

JAPANESE-FILIPINO
BROTHERHOOD ASSN.

MORISITA
BUTAI

HIRATA-TAI

GANAP

STANDING ARMY OF
THE PHILIPPINES

(Specify each below)

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

NEW UNITY

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

YES

NO

17B. ORGANIZATIONS (Check all boxes that apply)

(If "YES," complete Item 17B)

BUREAU OF CONSTABULARY

MUNICIPAL POLICE FORCE

MANILA DEFENSE CORPS

PHILIPPINE CONSTABULARY

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
THE RESISTANCE MOVEMENT?

YES

NO

B. GIVE DETAILS

(If "YES," complete Item 18B)

C. GIVE THE NAMES OF PERSONS OR UNITS YOU ASSISTED

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

YES

NO

E. STATE HOW AND BY WHOM

(If "YES," complete Item 18E)

F. DURING YOUR SERVICE IN THE ORGANIZATION DID YOU EVER DESERT OR LEAVE YOUR JOB?
YES

NO

(If "YES," check one
of the following)

19A. DURING YOUR SERVICE DID YOU EVER
ATTEMPT TO FIND OTHER WORK?

YES
VA FORM
AUG 2011

NO

(If "YES," complete
Item 19B)

21-4169

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?

(If "YES," complete Items 21B through 21G). (If "No," skip to Item 22A).
YES
NO
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
22B.
22C.

NO

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

PHILIPPINE GOVERNMENT BENEFITS

ARREARS IN PAY (back pay)
FROM PHIL COM
PENSION WITH PHILIPPINE
VETERAN'S BOARD

AMOUNT OF SETTLEMENT

DATE

CLAIM NO.

OFFICE WITH WHICH FILED

AMOUNT OF PENSION

DATE

CLAIM NO.

OFFICE WITH WHICH FILED

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
NO
(If "YES," Complete Items 23B through 23F). (If "No," skip to Item 24).
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

VA FORM
AUG 2011

21-4169

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, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and
Employment 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send
comments or suggestions about this form.

25.CERTIFICATION
(have read)
(have had read to me) all the questions and answers in this application, that the answers to all the
I HEREBY CERTIFY THAT I
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)

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

SIGNATURE OF WITNESS

DATE

WITNESS TO THUMBPRINT

DATE

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

SIGNATURE OF WITNESS

VA FORM
AUG 2011

21-4169

DATE