Form VA Form 21-526b VA Form 21-526b Veterans Supplemental Claim Application

OMB Control No. 2900-0001
Respondent Burden: 15 minutes
Expiration Date: X/XX/XXXX
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

VETERAN'S SUPPLEMENTAL CLAIM FOR COMPENSATION

INSTRUCTIONS: Please read the Privacy Act Notice and Respondent Burden information on Page 2 before
completing this form. If you have any questions about this form, call VA toll-free at 1-800-827-1000 (Hearing
Impaired TDD federal relay number is 711). Also, see mail/fax information and information about completing
the form online on Page 2.
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 of the form.

SECTION I - VETERAN'S IDENTIFICATION INFORMATION

1. VETERAN'S NAME (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

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

3. VA FILE NUMBER

Month

Day

Year

5. VETERAN'S SERVICE NUMBER (If applicable)

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

Apt./Unit Number
State/Province

ZIP Code/Postal Code

Country

7. TELEPHONE NUMBER (Include Area Code)

8. EMAIL ADDRESS (Optional)

SECTION II: CLAIM INFORMATION
9A. LIST THE CURRENT DISABILITY(IES) OR SYMPTOMS THAT YOU CLAIM ARE RELATED TO YOUR MILITARY SERVICE AND/OR SERVICECONNECTED DISABILITY (If applicable, identify whether a disability is due to a service-connected disability; confinement as a prisoner of war; exposure to Agent
Orange, asbestos, mustard gas, ionizing radiation, or Gulf War environmental hazards; or a disability for which compensation is payable under 38 U.S.C. 1151)
NOTE: List your claimed conditions below. See the following three examples for guidance on how to complete Section II.
EXAMPLES OF DISABILITY(IES)

EXAMPLES OF EXPOSURE
TYPE

Example 1. HEARING LOSS

NOISE

Example 2. DIABETES

AGENT ORANGE

Example 3. LEFT KNEE, SECONDARY TO RIGHT KNEE

CURRENT DISABILITY(IES)

IF DUE TO EXPOSURE, EVENT, OR
INJURY, PLEASE SPECIFY
(e.g., Agent Orange, radiation)

EXAMPLES OF HOW THE
DISABILITY(IES) RELATE TO SERVICE

EXAMPLES OF DATES

HEAVY EQUIPMENT OPERATOR IN SERVICE

JULY 1968

SERVICE IN VIETNAM WAR

DECEMBER 1972

INJURED LEFT KNEE WHEN BRACE ON
RIGHT KNEE FAILED

6/11/2008

EXPLAIN HOW THE DISABILITY(IES)
RELATES TO THE IN-SERVICE
EVENT/EXPOSURE/INJURY

APPROXIMATE DATE
DISABILITY(IES)
BEGAN OR WORSENED

1.

2.

3.

4.

5.

6.
VA FORM
XXX XXXX

21-526b

SUPERSEDES VA FORM 21-526b, JUN 2014,
WHICH WILL BE USED.

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VETERAN'S SOCIAL SECURITY NO.

SECTION II: CLAIM INFORMATION (Continued)
IF DUE TO EXPOSURE, EVENT, OR
INJURY, PLEASE SPECIFY
(e.g., Agent Orange, radiation)

CURRENT DISABILITY(IES)

EXPLAIN HOW THE DISABILITY(IES)
RELATES TO THE IN-SERVICE
EVENT/EXPOSURE/INJURY

APPROXIMATE DATE
DISABILITY(IES)
BEGAN OR WORSENED

7.

8.

9.

10.
9B. LIST VA MEDICAL CENTER(S) (VAMC) AND DEPARTMENT OF DEFENSE (DOD) MILITARY TREATMENT FACILITIES (MTF) WHERE YOU
TREATMENT AFTER DISCHARGE FOR YOUR CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES:

A. NAME AND LOCATION

RECEIVED

B. DATE(S) OF TREATMENT

9C. DO YOU HAVE PRIVATE TREATMENT RECORDS?
YES

NO

(If "Yes," please attach the treatment records to this form. If you would like to have VA request your private treatment
records, please attach a VA Form 21-4142, Authorization and Consent to Release Information to the Department of
Veterans Affairs, for each private treatment provider. The form is available at www.va.gov/vaforms.)

10. I WOULD LIKE TO FILE A CLAIM FOR OTHER VA BENEFITS (Check appropriate box)
AID AND ATTENDANCE

OTHER (Specify benefit)

AUTOMOBILE ALLOWANCE

11A. IF YOU WOULD LIKE TO FILE A CLAIM FOR ADDITIONAL BENEFITS
BECAUSE YOUR SPOUSE IS SERIOUSLY DISABLED (Please check
the box and provide your spouse's name and social security number
in Items 12B & 12C)

11B. SPOUSE'S SOCIAL SECURITY NUMBER

11C. SPOUSE'S NAME (First, Middle Initial, Last)

SECTION III - CERTIFICATION AND SIGNATURE
I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge and belief.
12B. DATE SIGNED (MM/DD/YYYY)

12A. VETERAN'S SIGNATURE (Do NOT print) (Sign in ink)
MAIL TO:
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

FAX TO:
844-531-7818 (Toll Free) OR
For Foreign Claims 248-524-4260

ONLINE:
www.ebenefits.gov

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. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN 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 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. The responses you submit are considered confidential (38 U.
S.C. 5701). 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.
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. 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.
PENALTY: The law provides severe penalties which include a fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.
VA FORM 21-526b, XXX XXXX

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