0918b Application for Monthly Assistance Allowance For Veteran

OMB Number: 2900-0760
Exp. Date: January, 2018
Respondent Burden: 20 minutes

APPLICATION FOR MONTHLY ASSISTANCE ALLOWANCE FOR VETERANS IN
CONNECTION WITH THE UNITED STATES PARALYMPICS

PRIVACY ACT: The information requested on this form is solicited under the authority of Title 38, U.S.C., and Sections 1710, 1712, and 1722. It is
being collected to enable us to determine your eligibility for benefits and will be used for that purpose. The information you supply may be verified
through a computer matching program at any time and information may be disclosed outside the VA as permitted by law. VA may make a routine use
disclosure of the information as outlined in the Privacy Act system of records identified as 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, the
information is required in order for us to determine your eligibility for the benefit for which you have applied. Failure to furnish the information will
have no adverse affect on any other benefits to which you may be entitled.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

.

1. NAME AND MAILING ADDRESS OF APPLICANT

SECTION A - IDENTIFYING DATA

.

2. VA FILE NUMBER (If applicable)

3. VETERANS SOCIAL SECURITY NO.
(Last 4-digits only)
1A. HAVE YOU RECEIVED A VA-RATING FOR A SERVICE CONNECTED DISABILITY?
4. NAME OF SPORT

YES

NO

SECTION B - UNITED STATES PARALYMPICS SPORT TRAINING

5. NAME OF GOVERNING ORGANIZATION
6. LOCATION OF TRAINING
7. NAME AND TITLE OF CERTIFYING PARALYMPICS OFFICIAL (Applicants must be invited to participate in Paralympics training by the applicable governing
Paralympics sport entity in the United States to receive a VA allowance)

SECTION C - DECLARATION OF DEPENDENT STATUS
VETERAN'S MARRIAGES
8A. HOW MANY TIMES HAVE YOU BEEN MARRIED? (Including current marriage)

8B. DATE AND PLACE
OF MARRIAGE
(City,/State or Country)

8C. TO WHOM MARRIED
(First, middle, last name)

8D. SPOUSE
SSN
(Last 4-digits only)

8E. HOW
MARRIAGE
TERMINATED
(Death, Divorce)

8F. DATE AND PLACE
TERMINATED
(City/State or Country)

MOST RECENT MARRIAGE

Place:

month day year
Place:

month day year

PREVIOUS MARRIAGE 1

Place:

month day year

Place:

month day year

PREVIOUS MARRIAGE 2

Place:

month day year

9. DO YOU LIVE WITH YOUR SPOUSE? (If "yes", skip to Item 12, if "no", answer Items 10 and 11)
VA FORM
JAN 2015

0918b

Place:
YES

NO

month day year

11. HOW MUCH DO YOU CONTRIBUTE MONTHLY TO YOUR
SPOUSES SUPPORT?

10. WHAT IS YOUR SPOUSE'S ADDRESS?

$

VETERAN'S UNMARRIED CHILDREN

Note: In Items 12A through 12I, check all boxes that apply.
12A.
NAME OF CHILD
(first, middle initial, last)

12B.
DATE AND PLACE OF
BIRTH
(city, state or country)

12C.
SOCIAL
SECURITY
NUMBER
(Last 4-digits only)

12D.
BIO LOGICAL

12E.
ADOPT ED

12F.
STEP CHILD

12G.
12I.
12H.
18-23 YRS.
CHILD
SERIOUSLY
OLD AND IN
PREVIOUSLY
DISABLED
SCHOOL
MARRIED

mo day yr

PLACE:

mo day yr

PLACE:

mo day yr

PLACE:

Note: If any of the children listed above don't live with you, complete Items 13A through 13C.
13A. NAME OF CHILD (First, middle initial, last)

13B. CHILD'S COMPLETE ADDRESS

13C. NAME OF PERSON THE CHILD LIVES
WITH (If applicable)

14. I hereby certify that the information given above is true and correct to the best of my knowledge and belief.
15A. SIGNATURE OF CLAIMANT

16. DAYTIME TELEPHONE NUMBER

VA FORM 0918b, JAN 2015, page 2

15B. DATE SIGNED

17. EVENING TELEPHONE NUMBER