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

OMB Approved No. 2900-0094
Respondent Burden: 15 minutes
Expiration XXX/XX/XXXX

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 28 "Remarks" and identify your answers by the item
numbers to which they apply.
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to
expedite processing the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER

2. SOCIAL SECURITY NUMBER (If one has been assigned)

4. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

5. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II - CLAIMANT'S IDENTIFICATION INFORMATION
(Please Complete Section II If Other Than Veteran)
6. CLAIMANT'S NAME (First, Middle Initial, Last)

7. MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
Country

State/Province

ZIP Code/Postal Code
9. FULL MAIDEN NAME OF CLAIMANT'S MOTHER

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

10. NAME OF CLAIMANT'S FATHER

SECTION III - VETERAN'S SERVICE INFORMATION
NOTE: List each period of active service. Show all service numbers, if known.
11. BRANCH OF SERVICE IN WHICH VETERAN SERVED (Check if service is other than that shown in Items 12A-12G or 13A-13G)
ARMY

NAVY

AIR FORCE

11A. ENTERED SERVICE

COAST GUARD

11B. SERVICE NUMBER

PLACE

DATE

12A. ENTERED SERVICE

13A. ENTERED SERVICE

OTHER (Specify)

11C. SEPARATED FROM SERVICE
DATE

12C. SEPARATED FROM SERVICE
DATE

21-4169

PLACE

12D.
12E.
DIVISION REGIMENT

12F.
COMPANY

12G.
RANK

13D.
13E.
DIVISION REGIMENT

13F.
COMPANY

13G.
RANK

GUERILLA ORGANIZATION
13B. SERVICE NUMBER

13C. NAME OF ORGANIZATION

PLACE

DATE

11D. GRADE AND ORGANIZATION

PLACE

PHILIPPINE ARMY
12B. SERVICE NUMBER

PLACE

DATE

VA FORM
XXX XXXX

MARINE CORPS

SUPERSEDES VA FORM 21-4169, NOV 2014,
WHICH WILL NOT BE USED.

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VETERAN'S SOCIAL SECURITY NO.

NOTE: Complete Items 14A through 18D only, if VA Form 21-526 is submitted. Skip to Item 19, if VA Form 21P-534 or 21P-535 is submitted.
14B. DATE EXAMINED

14A. WERE YOU GIVEN A PHYSICAL EXAMINATION WHEN YOU ENLISTED AND/OR RETURNED TO MILITARY CONTROL?
YES

NO

(If "Yes," explain in Items 14B and 14C) (If "No," skip to Item 15A)

14C. PLACE OF EXAMINATION (Address)

YES

NO

(If "Yes," explain in Item 15B)
16B. AFFIDAVITS FROM COMRADES MUST BE FURNISHED (Check one)

16A. DID YOU HAVE A COMBAT WOUND OR INJURY DURING ACTIVE SERVICE IN
WORLD WAR II?

AFFIDAVITS
ATTACHED

NO (If "Yes," complete Item 16B)

YES

15B. MILITARY CHARGES

15A. AT THE TIME OF YOUR SEPARATION FROM SERVICE WERE
THERE ANY COURT MARTIAL OR OTHER MILITARY CHARGES?

AFFIDAVITS WILL BE FURNISHED
AT A LATER DATE

17. 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)
18A. ARE YOU NOW RECEIVING
18B. DATE
HOSPITALIZATION OR
ENTERED
INSTITUTION
DOMICILIARY CARE FROM THE
PHILIPPINE GOVERNMENT OR
ANY OF ITS SUBDIVISIONS?

18C. DISABILITY FOR WHICH YOU WERE
TREATED IN THIS INSTITUTION

18D. NAME AND ADDRESS OF INSTITUTION

(If "Yes," complete Items

YES

NO 18B, 18C & 18D)

SECTION IV - ACTIVITIES OF CLAIMANT DURING JAPANESE OCCUPATION
19. WHERE DID YOU LIVE DURING THE FOLLOWING YEARS:

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

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

1942

1942

1943

1943

1944

1944

1945

1945

20A. WERE YOU A MEMBER OF ANY PRO-JAPANESE, PRO-GERMAN OR ANTI-AMERICAN-FILIPINO ORGANIZATIONS?

(If "Yes," complete Items 20B and 21) (If "NO," skip to Item 22)
YES
NO
20B. ORGANIZATIONS (Check all boxes that apply)
OTHER PRO-JAPANESE OR PRO-GERMAN OR
ANTI-AMERICAN-FILIPINO ORGANIZATIONS

MAKAPILI

PAMPAR

MATSUYAMA
BUTAI

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
21. GIVE FACTS, CIRCUMSTANCES, AND REASON FOR JOINING THE ORGANIZATION(S) CHECKED IN ITEM 20B (Give details)
YOIN

NEW UNITY

21A. DID YOU BELONG TO ANY OF THE ORGANIZATIONS LISTED IN ITEM 20B
DURING THE JAPANESE OCCUPATION?

21B. ORGANIZATIONS (Check all boxes that apply)
BUREAU OF CONSTABULARY

YES

NO

(If "YES," complete Item 21B)

VA FORM 21-4169, XXX XXXX

MANILA DEFENSE CORPS

MUNICIPAL POLICE FORCE
PHILIPPINE CONSTABULARY

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VETERAN'S SOCIAL SECURITY NO.

IMPORTANT: IF YOU WERE A MEMBER OF ANY OF THE ORGANIZATIONS LISTED IN ITEM 20B, COMPLETE ITEMS 22A THROUGH 22F.
22A. DID YOU AT ANY TIME OR IN ANY WAY ASSIST ANY GUERILLA UNITS OR
THE RESISTANCE MOVEMENT?

YES

22B. GIVE DETAILS

(If "YES," complete Item 22B)

NO

22C. GIVE THE NAMES OF PERSONS OR UNITS YOU ASSISTED

22D. WERE YOUR SERVICES RECOGNIZED BY THE GUERILLAS OR LEADERS
OF THE RESISTANCE MOVEMENT?

YES

22E. STATE HOW AND BY
WHOM

(If "YES," complete Item 22E)

NO

22F. DURING YOUR SERVICE IN THE ORGANIZATION DID YOU EVER DESERT OR LEAVE YOUR JOB?
YES

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

NO

23A. DURING YOUR SERVICE DID YOU EVER
ATTEMPT TO FIND OTHER WORK?
YES

YOU WERE REGARDED
AS AWOL

YOU RETURNED OF YOUR
OWN FREE WILL

YOU WERE PUNISHED
FOR LEAVING

23B. WHY NOT?

(If "YES," complete
Item 23B)

NO

24. 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?
YES
(If "YES," give the facts, circumstances and nature of the oath below):
NO

25A. 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 25B through 25G) (If "No," skip to Item 26A)
25C. NAME OF PERSON ACCUSED

25B. NAME OF ACCUSING AGENCY

25E. PLACE

25D. DATE ACCUSED

25F. NATURE OF THE CHARGE

25G. OUTCOME OF THE CASE

SECTION V - MISCELLANEOUS INFORMATION
26A. HAVE YOU EVER APPLIED FOR ANY BENEFITS FROM THE PHILIPPINE GOVERNMENT?
YES

NO

(If "YES," check Item 26B and/or Item 26C and complete information requested) (If "No," skip to Item 27)

26B.
ARREARS IN PAY (back pay)
FROM PHIL COM
26C.

PHILIPPINE GOVERNMENT BENEFITS
AMOUNT OF SETTLEMENT

DATE

CLAIM NO.

OFFICE WITH WHICH FILED

AMOUNT OF PENSION

DATE

CLAIM NO.

OFFICE WITH WHICH FILED

PENSION WITH PHILIPPINE
VETERAN'S BOARD

NOTE: IF CLAIMANT IS THE WIDOW OF THE VETERAN, FURNISH THE FOLLOWING INFORMATION:
27A. HAVE YOU LIVED AS THE WIFE OF ANY MAN SINCE THE DEATH OF THE VETERAN?
YES

NO

(If "YES," complete Items 27B through 27F) (If "No," skip to Item 28)

27B. FULL NAME OF PERSON WITH WHOM YOU LIVED

VA FORM 21-4169, XXX XXXX

27C. ADDRESS OF PERSON WITH WHOM YOU LIVED

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VETERAN'S SOCIAL SECURITY NO.
27D. BEGINNING DATE OF THIS RELATIONSHIP (Give month, day and year)

27E. PLACE OF RESIDENCE DURING EXISTENCE OF THIS RELATIONSHIP

27F. WERE ANY CHILDREN BORN TO THIS RELATIONSHIP?
YES

NO

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

DATE OF BIRTH

PLACE OF BIRTH

28. REMARKS

I HEREBY CERTIFY THAT I

(have read)

SECTION VI - CERTIFICATION

(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) (Sign in ink)

DATE

WITNESS TO THUMBPRINT

PRINT NAME (First-Middle-Last) AND ADDRESS OF WITNESS NUMBER 1

SIGNATURE OF WITNESS (Sign in ink)

DATE

PRINT NAME (First-Middle-Last) AND ADDRESS OF WITNESS NUMBER 2

SIGNATURE OF WITNESS (Sign in ink)

DATE

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, 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.

VA FORM 21-4169, XXX XXXX

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