VA Form 21-526 Veteran's Application for Compensation and/or Pension

INFORMATION AND INSTRUCTIONS FOR COMPLETING
VETERAN’S APPLICATION FOR
COMPENSATION AND/OR PENSION
IMPORTANT- Please read the information below carefully before completing the form. These instructions
include questions regarding this form. The answers should help you fill out your form more quickly and
accurately. In addition to these instructions, some parts of the form contain notes or specific instructions for
completing that part.
Frequently Asked Questions
For what do I use VA Form 21-526?
Use VA Form 21-526 to apply for compensation and/or pension benefits.
Should I apply for compensation or pension benefits?
You should apply for compensation benefits if:
You currently have a disability that is the result of an injury, disease, or
an event in military service.
You should apply for pension benefits if all of the following are true:
You are age 65 or older or are permanently and totally disabled.
You served on active duty with at least one day during a period of war.
Your income and net worth does not exceed certain limits. Visit our website,
http://www.vba.va.gov/bln/21/rates for the maximum yearly income we allow.
NOTE: Attach current medical evidence showing that you are permanently and totally disabled.
IMPORTANT: If you are a veteran who is age 65 or older, or determined to be disabled by the Social Security
Administration, you DO NOT have to submit medical evidence with your application unless you are filing for special
monthly pension.

What parts of the form should I complete?
You should complete only the parts related to the benefit for which you are applying:
If you are applying for compensation ONLY, skip parts VII, VIII, IX, X.
If you are applying for pension, complete the ENTIRE form.
If you need more space to answer a question or have a comment about a specific item on
this form, please place it in Part XIII, Item 45, "Remarks." Please identify your answer or
comment by the part and item number.

VA FORM
SEP 2009

21-526

SUPERSEDES VA FORM 21-526, JAN 2004, WHICH
WILL NOT BE USED.

PAGE 1

Where can I get help?
You can ask VA to help you fill out the form by contacting a regional office or call center. Before you contact us,
make sure you gather the necessary materials and complete as much of the form as you can. You can contact VA in
the following ways:
By internet:
https://iris.va.gov
In person:
You can locate the address of the closest regional office on the website http://www.va.gov/directory
or in your telephone book blue pages under "United States Government, Veterans"
By telephone:
Please call one of the following telephone numbers:
1-800-827-1000
1-800-829-4833 (Hearing Impaired TDD line)
1-412-395-6272 (If living outside the U.S.)
You can also contact a county or national veterans’ service organization (VSO) representative to help you with your
claim. If you want to use a representative to help you, consult your local telephone book to contact a particular VSO
or contact the closest VA office. Depending on the type of representative you want to designate, we will send you one
of the following forms:
VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative
VA Form 21-22A, Appointment of Individual as Claimant’s Representative
SOCIAL SECURITY BENEFITS - The Social Security And Supplemental Security Income disability programs are
the largest of several Federal programs that provide assistance to people with disabilities. While these two programs
are different in many ways, both are administered by the Social Security Administration (SSA) and only individuals
who have a disability and meet medical criteria may qualify for benefits under either program.
How can I contact SSA if I have questions?
If you have a question, call the SSA toll-free phone number at 1-800-772-1213, Monday through Friday, from 7a.m.
to 7p.m. If you have a touch-tone phone, recorded information and services are available 24 hours a day, including
weekends and holidays. People who are deaf or hard of hearing may call the toll-free TTY number, 1-800-325-0778,
between 7a.m. and 7p.m., Monday through Friday. Please have your Social Security number handy when you call.
You can also contact SSA in the following ways:
By mail:
You can locate the address of the closest SSA office in your telephone book blue pages under
"United States Government, Social Security Administration"
By internet:
http://www.ssa.gov/
What should I do when I have finished my application?
You should provide your signature in Part XII, Item 42A. Be sure to sign every form you fill out
before you send it to us. If you don’t sign the form, VA will return it for you to sign, and it will
take longer for us to process.
Attach any materials that support and explain your claim.
Mail or take your application to the closest VA regional office.
Do I need to keep a copy of my application?
It is important that you keep a copy of all completed forms and materials you give to VA.
PAGE 2

SPECIFIC INSTRUCTIONS FOR VA FORM 21-526
Part II - Nature and History of Disability(ies)
What disabilities should I list?
List the disease(s) or medical condition(s) that a doctor has diagnosed. Be as specific as you can. Indicate the
approximate date the disability began with the place of treatment.
Do I have to include any records with this claim form?
If you have records that support your claim, you should attach them to this form. VA will help you obtain records by
requesting them from the person, company, or agency that has them. On this form you must tell us the name and
address of the person, company or agency that has these records, the approximate time frame covered by them, and
the condition for which you were treated. If you received treatment, complete the attached VA Form 21-4142,
Authorization and Consent to Release Information to the Department of Veterans Affairs (VA). We will use this form
to request these records. Due to Privacy Act regulations, please list only one source of information (Item 7) on each
form, as some medical offices will not accept the forms otherwise, which may cause a delay in processing your claim.
Additional 21-4142 forms can be downloaded from the VA forms website at www.va.gov/vaforms .
Part III - Active Duty Service Information
Do I need to include my active duty service information?
Please provide the information for each period of active duty (provide a copy of your DD214 or other separation
papers for all periods of active duty service).
Part IV - Reserve and National Guard Service Information
What If I have Reserve or National Guard Service?
This section tells us if you were a member of the Reserve or National Guard. Complete information for each period of
Reserve and National Guard service. Provide a copy of your DD214 or other separation papers for all periods of
active service.
Part V - Military Retired/Severance Pay
What If I have received or will receive military pay?
If you currently receive military retired pay, we may reduce your retired pay by the amount of any compensation that
we award. This is to your advantage because VA compensation is not taxable while retired pay is taxable. However, if
you wish to receive military retired pay rather than VA compensation, you must check the box in Item 25. Some
veterans receive various readjustment, separation, or severance pay from service departments which may be recouped
in full or in part from VA benefit payments. This section tells us about your military severance or separation pay, the
type, and the amount.
Part VI - Marital and Dependency Information
Who can I count as a dependent spouse?
A spouse is a person of the opposite sex who is married to the veteran (Authority: 38 U.S.C. subsection 101(31)). The
marriage must be valid under the law of the place where the parties resided at the time of marriage, or the law of the
place where the parties resided when the right to benefits occurred.
Note: It is important that we know the marital history of you and your spouse.
Who can be recognized as a dependent child?
VA recognizes the veteran’s biological child, adopted child, and stepchild. However, the child must be unmarried
and:
be under the age of 18, or
be at least 18 but under 23 and pursuing an approved course of education, or
have become permanently unable to support themselves before reaching the age of 18.
PAGE 3

SPECIFIC INSTRUCTIONS FOR VA FORM 21-526 (Continued)
Part VII - Nonservice-Connected Pension
This section asks you to give us the disabilities that prevent you from working. We also ask you to tell us if you
require the regular assistance of another person, if you are housebound, if you are in a nursing home, if you are in
receipt of Social Security, or if you have applied for Medicaid.
Part VIII - Income Information
This section asks you to give us specific information about the monthly income you and your dependents receive from
all sources. Report the gross amount you receive monthly before deductions are taken out for taxes, insurance, health
care, etc. Do not leave any blank boxes in this section! Complete each box with either a dollar figure, "0", or "none."
If you expect to receive payment, but you don’t know how much it will be, write "Unknown" in the space. If you are
not sure about a particular type of income, report it and provide a full explanation of its source. If you are receiving
monthly benefits and have a copy of your most recent award letter, please include a copy of the letter with your
application.
Part IX - Net Worth
This section asks you to give us specific information about your net worth and the net worth of your dependents. Do
not leave any blank boxes in this section! Complete each box with either a dollar figure, "0", or "none." If you and
your spouse jointly share assets (such as money in a joint checking account), please clearly indicate this. You must
include all assets in your net worth except those items you use everyday. Report farms or buildings that you or a
dependent own by reporting its value as "real property."
Net worth is the market value of all interest and rights in any kind of property less any mortgages or other claims
against the property. However, net worth does not include the house in which you live or a reasonable area of land on
which it sits. Net worth also does not include the value of personal things you use everyday like your vehicle,
clothing, and furniture.
Applicant’s applying for VA pension must disclose all financial transactions that involve a transfer of assets, even if
the transaction occurred prior to the date of your application for VA pension. A gift of property or sale below the
value of property made by you to a relative residing in the same household is not recognized as reducing net worth. A
gift of property to someone other than a relative residing in your household is not recognized as reducing net worth
unless it is clear that you have relinquished all rights of ownership, including the right of control of the property.
Part X - Medical, Legal or Other Expenses
When determining your eligibility for pension, we may be able to deduct unreimbursed medical expenses from your
income for the year in which the expenses are paid. Report the amount of unreimbursed medical expenses, including
the Medicare deduction you paid (out-of-pocket) for yourself or relatives you are under an obligation to support. Also,
show medical, legal, or other expenses you paid because of a disability for which civilian disability benefits have been
awarded. Do not report any expenses you did not pay or expenses for which you were or will be reimbursed.

PRIVACY ACT INFORMATION: 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 voluntary; however, no allowance of compensation or pension may be granted unless this form is completed fully as required by law.
Giving us your and your dependents’ Social Security numbers is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for
whom benefits are claimed 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 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
Federal or state agencies. Income and employment information furnished by you will be compared with information obtained by VA from the Secretary of Health
and Human Services or the Secretary of the Treasury under clause (viii) of section 6103(1)(7)(D) of the Internal Revenue Code of 1986.
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation and/or pension (38 U.S.C. 5101). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 1 hour 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.
PAGE 4

OMB Control No. 2900-0001
Respondent Burden: 1 hour

VETERAN’S APPLICATION FOR COMPENSATION AND/OR PENSION
IMPORTANT - Read information and instructions carefully before completing the form. Type, print,
or write plainly.

(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

PART I - VETERAN’S INFORMATION
1. WHAT ARE YOU APPLYING FOR?
COMPENSATION
PENSION
COMPENSATION AND PENSION
2. HAVE YOU PREVIOUSLY APPLIED FOR ANY VA BENEFIT(S)? (Check applicable box)
PENSION

COMPENSATION

OTHER (Specify)

3. FIRST, MIDDLE, LAST NAME OF VETERAN

4A. VETERAN’S SOCIAL SECURITY NO. 4B. VA FILE NUMBER (If applicable)

4C. SPOUSE’S SOCIAL SECURITY NO.

4D. IF YOU SERVED UNDER ANOTHER NAME, GIVE NAME AND PERIOD DURING WHICH YOU SERVED AND SERVICE NO.
5. MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

7. E - MAIL ADDRESS (If applicable)

6. TELEPHONE NUMBER(S) (Include Area Code)
B. EVENING
C. CELL

A. DAYTIME

8A. DATE OF BIRTH (Month, day, year)

8B. PLACE OF BIRTH

10A. HAVE YOU EVER FILED A CLAIM FOR COMPENSATION
FROM THE OFFICE OF WORKERS’ COMPENSATION PROGRAMS?
(Formerly the U.S. Bureau of Employees Compensation)

10B. WHEN WAS THE CLAIM FILED?
(Mo., day, yr.)

YES

9. SEX
FEMALE
MALE
10C. FOR WHAT DISABILITY ARE YOU RECEIVING
BENEFITS?

(If "Yes," complete Items 10B & 10C)

NO

PART II - NATURE AND HISTORY OF DISABILITY(IES) - Please use the "Remarks" section for additional disability(ies)
11. PLEASE PROVIDE NATURE OF SICKNESS, DISEASE, OR INJURIES FOR WHICH THIS CLAIM IS MADE; DATE EACH BEGAN; AND PLACE OF TREATMENT

A. LIST DISABILITY(IES)

B. DATE BEGAN

12A. ARE YOU NOW OR HAVE YOU RECEIVED TREATMENT
OR DOMICILIARY CARE AT A VA MEDICAL FACILITY?

YES

C. PLACE OF TREATMENT

12B. DATES OF TREATMENT/CARE

Month

Day

Year

NO (If "Yes,"complete Items 12B &12C)

13A. HAVE YOU EVER BEEN A PRISONER OF WAR?

13B. NAME OF COUNTRY
FROM

YES
NO (If "Yes," complete Items 13B and 13C)
14. ARE YOU CLAIMING A DISABILITY RELATED TO AGENT ORANGE OR
OTHER HERBICIDE EXPOSURE? (If "Yes," list disability(ies) below)
YES

NO

NO

17. ARE YOU CLAIMING A DISABILITY RELATED TO IONIZING RADIATION
EXPOSURE? (If ’Yes," list disability(ies) below)
YES

NO

13C. DATES OF CONFINEMENT
TO

15. ARE YOU CLAIMING A DISABILITY RELATED TO ASBESTOS
EXPOSURE? (If "Yes," list disability(ies) below)
YES

16. ARE YOU CLAIMING A DISABILITY RELATED TO MUSTARD GAS
EXPOSURE? (If "Yes," list disability(ies) below)
YES

12C. NAME AND ADDRESS OF VA MEDICAL FACILITY
(If you need more space use Item 45, "Remarks")

NO

18. ARE YOU CLAIMING A DISABILITY RELATED TO AN ENVIRONMENTAL HAZARD EXPOSURE DURING THE GULF WAR? (If "Yes," list disability(ies)
below)

YES

NO

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 42A THRU 42C ON PAGE 10.
VA FORM
SEP 2009

21-526

SUPERSEDES VA FORM 21-526, JAN 2004, WHICH
WILL NOT BE USED.

PAGE 5

PART III - ACTIVE DUTY SERVICE INFORMATION

NOTE: Please complete the information for each period of active duty. Attach DD214 or other separation papers for all periods of
active duty. If you do not have your DD214 form or other separation papers, check the box.
19A. ENTERED INTO SERVICE
DATE

19B. SERVICE NUMBER

PLACE

19C. SEPARATED FROM SERVICE
DATE

19D. BRANCH OF
SERVICE

19E. GRADE, RANK OR
RATING, ORGANIZATION

PLACE

PART IV - RESERVE AND NATIONAL GUARD SERVICE INFORMATION

NOTE: Enter complete information for each period of Reserves and National Guard service. Attach any separation papers you have.
20A. ENTERED INTO SERVICE
DATE

20B. SERVICE NUMBER

PLACE

20C. SEPARATED FROM SERVICE
DATE

20D. SERVICE STATUS
(Reserve, National Guard)

20E. GRADE, RANK OR
RATING, ORGANIZATION

PLACE

21. IF DISABILITY OCCURRED DURING ACTIVE OR INACTIVE DUTY 22A. ARE YOU NOW A MEMBER OF THE RESERVES OR 22B. RESERVE STATUS
NATIONAL GUARD? IF SO, GIVE THE BRANCH
FOR TRAINING, GIVE BRANCH OF SERVICE AND DATE OF
RESERVE
OF SERVICE
OCCURRENCE
ACTIVE
OBLIGATION
BRANCH_______________________
YES
NO
INACTIVE
22C. NAME, ADDRESS AND PHONE NO. OF RESERVES OR NATIONAL GUARD UNIT (If additional space is needed, use Item 45 "Remarks")

PART V - MILITARY RETIRED/SEVERANCE PAY
IMPORTANT - Unless you check the box in Item 25 below, you are telling us that you are choosing to receive VA compensation instead of military
retired pay, if it is determined you are entitled to both benefits. If you are awarded military retired pay prior to compensation, we will reduce your
retired pay by the amount of any compensation that you are awarded. VA will notify the Military Retired Pay Center of all benefit changes. If you
receive both military retired pay and VA compensation, some of the amount you receive may be recouped by VA, or, in the case of Voluntary
Separation Incentive (VSI), by the Department of Defense.
23A. ARE YOU RECEIVING MILITARY
RETIRED PAY? (If "Yes," complete
Items 23C & 23D)

23B. WILL YOU RECEIVE MILITARY RETIRED PAY IN THE
FUTURE? (If "Yes," explain, i.e. Future Reserve/National Guard
Retirement, Pending MEB/PEB)

YES

YES
NO
24. RETIRED STATUS

23C. BRANCH OF
SERVICE

23D. MONTHLY
AMOUNT

$

NO

25. NO, I DO NOT WANT VA COMPENSATION IN LIEU OF MILITARY RETIRED PAY
(Check box, if applicable)

TEMPORARY DISABILITY
DISABLED
RETIRED
RETIRED LIST
RETIRED LIST
26. HAVE YOU EVER APPLIED FOR OR RECEIVED DISABILITY SEVERANCE/SEPARATION PAY, OR ANY OTHER LUMP SUM PAYMENT FROM THE ARMED FORCES?
(If "Yes," list type, amount, date it was received, and the branch of service below)
YES

NO

PART VI - MARITAL AND DEPENDENCY INFORMATION
27A. MARITAL STATUS (If married, complete Items 27B thru 29D)

27B. SPOUSE’S BIRTHDATE (Mo., day, yr.)

MARRIED
WIDOWED
DIVORCED
NEVER MARRIED (If never married, skip to Item 30)
27C. NUMBER OF TIMES YOU 27D. NUMBER OF TIMES YOUR
27E. IS YOUR SPOUSE ALSO A VETERAN?
HAVE BEEN MARRIED
PRESENT SPOUSE HAS
(To include current marriage)
BEEN MARRIED (To include
current marriage)
YES
NO (If "Yes,"complete Item 27F)
27H. REASON FOR SEPARATION (For example,
marital problems, job requirements, health, etc.)

27G. DO YOU LIVE TOGETHER?

YES

NO

C27I. PRESENT ADDRESS OF SPOUSE

(If "No,"complete Items 27H thru 27J)

27J. AMOUNT YOU CONTRIBUTE TO YOUR
SPOUSE’S MONTHLY SUPPORT

$

27F. SPOUSE’S VA FILE NUMBER (If any)

27K. HOW WERE YOU MARRIED?
CLERGYMAN OR AUTHORIZED
PUBLIC OFFICIAL

TRIBAL

COMMON-LAW

PROXY

OTHER (Explain)

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 42A THRU 42C ON PAGE 10.
PAGE 6

PART VI - MARITAL AND DEPENDENCY INFORMATION - CONTINUED (If you need additional space, use Item 45 "Remarks")
FURNISH THE FOLLOWING INFORMATION ABOUT EACH OF YOUR MARRIAGES (IF NONE, WRITE "N/A")
28A. DATE AND PLACE OF MARRIAGE
MONTH, YEAR

28C. TERMINATED
(Death, Divorce)

28B. TO WHOM MARRIED

CITY, STATE

28D. DATE AND PLACE TERMINATED
MONTH, YEAR

CITY, STATE

FURNISH THE FOLLOWING INFORMATION ABOUT EACH PREVIOUS MARRIAGE OF YOUR PRESENT SPOUSE (IF NONE, WRITE "N/A")
29A. DATE AND PLACE OF MARRIAGE
MONTH, YEAR

29C. TERMINATED
(Death, Divorce)

29B. TO WHOM MARRIED

CITY, STATE

29D. DATE AND PLACE TERMINATED
MONTH, YEAR

CITY, STATE

DEPENDENCY - Dependent Children Information (If you need additional space, use Item 45 "Remarks")
FURNISH THE FOLLOWING INFORMATION FOR EACH OF YOUR DEPENDENT CHILDREN
30A. NAME OF CHILD
(First, middle initial, last)

30B. DATE & PLACE OF
BIRTH
(City, state or country)

30D. CHECK EACH APPLICABLE CATEGORY
30C. SOCIAL SECURITY
18-23 YRS.
SERIOUSLY
CHILD
NUMBER
DISABLED
PREVIOUSLY
BIOLOGICAL ADOPTED STEPCHILD OLD AND IN
SCHOOL BEFORE AGE 18 MARRIED

(Month, day, year)
Place:

(Month, day, year)
Place:

(Month, day, year)
Place:

FURNISH THE FOLLOWING INFORMATION FOR EACH OF YOUR DEPENDENT CHILDREN WHO DO NOT LIVE WITH YOU
31A. NAME(S) OF ANY CHILD(REN) NOT
IN YOUR CUSTODY

31C. MONTHLY AMOUNT YOU
CONTRIBUTE TO
CHILD’S SUPPORT

31B. NAME AND ADDRESS OF
PERSON HAVING CUSTODY

$
$
PART VII - NONSERVICE-CONNECTED PENSION (If you need additional space, use Item 45 "Remarks")
33. DO YOU NEED THE REGULAR ASSISTANCE OF ANOTHER PERSON OR ARE
YOU HOUSEBOUND?

32. WHAT DISABILITIES PREVENT YOU FROM WORKING? (List below)

YES

NO

NURSING HOME INFORMATION (If you are in a nursing home provide the following information)
NOTE: You may submit a statement by an official of the nursing home that tells us that you are a patient in the nursing home because of a
physical or mental disability. The statement should include the monthly charge you are paying out-of-pocket for your care.
34A. ARE YOU NOW IN A NURSING HOME?

34B. NAME AND COMPLETE MAILING ADDRESS OF THE FACILITY

(If "YES,"complete
Items 34B thru 34D)
34D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME COSTS OR HAVE YOU APPLIED AND NO DECISION
HAS BEEN MADE?
YES
NO
APPLIED - NO DECISION
YES

34C. HAVE YOU APPLIED FOR
MEDICAID?
YES

NO

NO

34E. ARE YOU RECEIVING SUPPLEMENTAL SOCIAL SECURITY INCOME (SSI) OR HAVE YOU
APPLIED FOR SSI BUT NO DECISION HAS BEEN MADE?
YES

NO

APPLIED - NO DECISION

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 42A THRU 42C ON PAGE 10.
PAGE 7

PART VIII - INCOME INFORMATION (Provide income you have received and you expect to receive from all sources)

NOTE: Report the total amounts before deductions for taxes, insurance, etc. If you do not receive any payments from one of the
sources that we list, write "0" or "None" in the space. If you are receiving monthly benefits, give us a copy of your most recent award
letter. This will help us determine the amount of benefits you should be paid. Payments from any source will be counted, unless the
law says that they don’t need to be counted.
MONTHLY INCOME - Provide the income that you and your dependents receive every month. For items 35A -35F, if none, write "0" or "NONE."
Do not leave blank spaces.
CHILD(REN) (Provide the first, middle initial, and last name)
ITEM
NO.

SOURCES OF
RECURRING MONTHLY
INCOME

35A.

Social Security

35B.

U.S. Civil Service

35C.

U.S. Railroad Retirement

35D.

Military Retired Pay

35E.

Black Lung Benefits

35F.

Other (Interest, dividends,
or one-time payments)

VETERAN

36A. WILL YOU RECEIVE ANY INCOME FROM
RENTAL PROPERTY OR FROM THE
OPERATION OF A BUSINESS WITHIN 12
MONTHS OF THE DAY YOU SIGN THIS
FORM?
YES

NO

NAME

SPOUSE

36B. WILL YOU RECEIVE ANY INCOME FROM
THE OPERATION OF A FARM WITHIN
12 MONTHS OF THE DAY YOU SIGN THIS
FORM?

YES

NO

NAME

NAME

36C. DO YOU THINK YOUR INCOME WILL CHANGE
IN THE NEXT 12 MONTHS? (If "Yes," explain
below)

YES

NO

PART IX - NET WORTH (Provide specific information about the net worth of you and your dependents)

NET WORTH is the market value of all interest and rights in any kind of property after subtracting any mortgages or other claims
against the property. However, net worth does not include the house you live in or a reasonable area of land it sits on. Net worth also
does not include the value of personal items such as your vehicle, clothing, and furniture.
NOTE: For Items 37A-37F provide amounts. If none, write "0" OR "NONE." Do not leave blank spaces.
CHILD(REN) (Provide the first, middle initial, and last name)
ITEM
NO.

SOURCE

37A.

Cash, non-interest
bearing bank accounts

37B.

Interest bearing bank
accounts, certificates of
deposit (CDs)

37C.

Retirement accounts (IRAs,
Keogh Plans, etc.)

37D.

Stocks, bonds, and
mutual funds

37E.

Value of business assets

37F.

Real property (not your
home)

VETERAN

SPOUSE

NAME

NAME

NAME

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 42A THRU 42C ON PAGE 10.
PAGE 8

PART X - MEDICAL, LEGAL OR OTHER EXPENSES
IMPORTANT - Complete items 38A through 38E only if you are applying for nonservice-connected pension.
MEDICAL, LEGAL OR OTHER EXPENSES - Family medical expenses you actually paid (out-of-pocket) may be deducted from your income. Show the
amount of unreimbursed medical expenses you paid for dependents you are under an obligation to support. Also, 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
increase benefits for the year in which the expenses are paid. Do not include any expenses for which you were reimbursed. Be sure to include the
Medicare deduction. If more space is needed, you may use Item 45, "Remarks" or attach a separate sheet.

38A. AMOUNT YOU PAID

38B. DATE
PAID
(Month, year)

38C. PURPOSE
(Doctor’s fees, hospital charges,
attorney fees, etc.)

38D. PAID TO
(Name of doctor, hospital, pharmacy, attorney,
etc.)

38E. PERSON FOR WHOM EXPENSE
PAID (Self, spouse, child)

PART XI - DIRECT DEPOSIT

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 39, 40, and 41
to enroll in direct deposit. If you do not have a bank account you can receive a waiver from direct deposit, just check the
box below in Item 39. You can also request a waiver if you have other circumstances that you feel would cause you a
hardship to be 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.
39. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)

CHECKING

(Account Number)

SAVINGS

(Account Number)

40. NAME OF FINANCIAL INSTITUTION (Please provide the name
of the bank where you want your direct deposit to go)

I certify that I do not have an account
with a financial institution or certified payment
agent
41. ROUTING OR TRANSIT NUMBER (The first nine numbers
located at the bottom left of your check or savings deposit slip)

YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 42A THRU 42C ON PAGE 10.
PAGE 9

PART XII - CERTIFICATION, AUTHORIZATION, AND SIGNATURE(S)
I certify that the statements in this document are true and complete to the best of my knowledge and belief. 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.
IMPORTANT - If you sign with an "X", then you must have 2 people witness your signature. They must then sign the form and print their names and
addresses.
42A. VETERAN’S SIGNATURE (Do not print) (Please sign in ink)

42B. VETERAN’S PRINTED NAME

42C. DATE SIGNED

43A. SIGNATURE OF WITNESS (Do not print)

43B. PRINTED NAME AND ADDRESS OF WITNESS

44A. SIGNATURE OF WITNESS (Do not print)

44B. PRINTED NAME AND ADDRESS OF WITNESS

PART XIII - REMARKS (Use this space for any additional statements that you would like to make
concerning your application for Compensation and/or Pension)
45. REMARKS (If you need more space you may attach a separate sheet of paper)

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.
YOU MUST SIGN AND PRINT YOUR NAME AND DATE THIS FORM IN ITEMS 42A THRU 42C ON THIS PAGE.
PAGE 10

OMB Control No. 2900-0001
Respondent Burden: 5 Minutes

AUTHORIZATION AND CONSENT TO RELEASE INFORMATION TO THE
DEPARTMENT OF VETERANS AFFAIRS (VA)
Important Notice About Information: We need this information to obtain your treatment records. Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 5 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/library/omb/OMBINVC.html#VA. If desired, you can
call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

IF YOU HAVE ANY QUESTIONS ABOUT THIS FORM, CALL VA TOLL-FREE AT 1-800-827-1000
(TDD 1-800-829-4833 FOR HEARING IMPAIRED)
SECTION I - VETERAN/CLAIMANT IDENTIFICATION
1. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

2. VETERAN’S VA FILE NUMBER

3. CLAIMANT’S NAME (If other than Veteran) LAST NAME, FIRST, MIDDLE

4. VETERAN’S SOCIAL SECURITY NUMBER

5. RELATIONSHIP OF CLAIMANT TO VETERAN

6. CLAIMANT’S SOCIAL SECURITY NUMBER

SECTION II - SOURCE OF INFORMATION
7A. LIST THE NAME AND ADDRESS OF THE SOURCE SUCH AS A PHYSICIAN,
HOSPITAL, ETC. (Include ZIP Codes, and also a telephone number, if available)

7B. DATE(S) OF TREATMENT,
HOSPITALIZATIONS, OFFICE
VISITS, DISCHARGE FROM
TREATMENT OR CARE, ETC.
(Include month and year)

7C. CONDITION(S)
(List illness, injury, etc.
pertinent to your claim)

8. COMMENTS

YOU MUST SIGN AND DATE THIS FORM ON PAGE 2 AND CHECK THE APPROPRIATE BLOCK IN ITEM 9C.
VA FORM
SEP 2009

21-4142

SUPERSEDES VA FORM 21-4142, MAY 2004, WHICH
WILL NOT BE USED.

PAGE 1

SECTION III - CONSENT TO RELEASE INFORMATION

READ ALL PARAGRAPHS CAREFULLY BEFORE SIGNING. YOU MUST CHECK THE APPROPRIATE STATEMENT
UNDERLINED IN PARENTHESES IN PARAGRAPH 9C.
9A. 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 Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is voluntary. However, if the
information including your Social Security Number (SSN) is not furnished completely or accurately, the health care provider to which this authorization is addressed
may not be able to identify and locate your records, and provide a copy to VA. VA uses your SSN to identify your claim file. Providing your SSN will help ensure
that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not
result in the denial of benefits. 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
Federal Statute of law in effect prior to January 1, 1975, and still in effect.

9B. I, the undersigned, hereby authorize the hospital, physician or other health care provider or health plan shown in Item 7A to release any information that may
have been obtained in connection with a physical, psychological or psychiatric examination or treatment, with the understanding that VA will use this information in
determining my eligibility to veterans benefits I have claimed. I understand that the health care provider or health plan identified in Item 7A who is being asked to
provide the Veterans Benefits Administration with records under this authorization may not require me to execute this authorization before it will, or will continue to,
provide me with treatment, payment for health care, enrollment in a health plan, or eligibility for benefits provided by it. I understand that once my health care
provider sends this information to VA under this authorization, the information will no longer be protected by the HIPPA Privacy Rule, but will be protected by the
Federal Privacy Act, 5 USC 552a, and VA may disclose this information as authorized by law. I also understand that I may revoke this authorization, at anytime
(except to the extent that the health care provider has already released information to VA under this authorization) by notifying the health care provider shown in
Item 7A. Please contact the VA Regional Office handling your claim or the Board of Veterans’ Appeals, if an appeal is pending, regarding such action. If you do not
revoke this authorization, it will automatically end 180 days from the date you sign and date the form (Item 10C).

9C. I
the source shown in Item 7A to release or disclose any information or
(AUTHORIZE)
(DO NOT AUTHORIZE)
records relating to the diagnosis, treatment or other therapy for the condition(s) of drug abuse, alcoholism or alcohol abuse, infection with
the human immunodeficiency virus (HIV), sickle cell anemia or psychotherapy notes. IF MY CONSENT TO THIS INFORMATION IS LIMITED, THE
LIMITATION IS WRITTEN HERE:

10A. SIGNATURE OF VETERAN/CLAIMANT OR LEGAL REPRESENTATIVE

10B. RELATIONSHIP TO VETERAN/CLAIMANT
(If other than self, please provide full name, title,
organization, city, State and ZIP Code. All court
appointments must include docket number, county
and State)

10D. MAILING ADDRESS (Number and Street or rural route, city, or P.O., State and ZIP Code)

10C. DATE

10E. TELEPHONE NUMBER (Include Area Code)

The signature and address of a person who either knows the person signing this form or is satisfied as to that person’s identity is requested below. This
is not required by VA but may be required by the source of the information.
11A. SIGNATURE OF WITNESS

11B. DATE

11C. MAILING ADDRESS OF WITNESS

VA FORM 21-4142, SEP 2009

PAGE 2