0918b Application for Monthly Assistance Allowance For Veteran

OMB Number: 2900-0760
Exp. Date: January, 2021
Respondent Burden: 20 minutes

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

SECTION A - IDENTIFYING DATA

.

.

1. NAME AND MAILING ADDRESS OF APPLICANT

1A. HAVE YOU RECEIVED A VA-RATING FOR
A SERVICE CONNECTED DISABILITY?
YES

NO

2. VETERANS SOCIAL SECURITY NO.
(Last 4-digits only)

SECTION B - UNITED STATES PARALYMPICS AND OLYMPICS SPORT TRAINING
3. NAME OF SPORT

4. NAME OF GOVERNING ORGANIZATION

5. LOCATION OF TRAINING

SECTION C - DECLARATION OF DEPENDENT STATUS
VETERAN'S MARRIAGES
6A. HOW MANY TIMES HAVE YOU BEEN MARRIED? (Including current marriage)

6B. DATE AND PLACE
OF MARRIAGE
(City,/State or Country)

6C. TO WHOM MARRIED
(First, middle, last name)

6D. SPOUSE
SSN
(Last 4-digits only)

6E. HOW
MARRIAGE
TERMINATED
(Death, Divorce)

6F. DATE AND PLACE
TERMINATED
(City/State or Country)

MOST RECENT MARRIAGE

month day year

month day year

Place:

Place:

PREVIOUS MARRIAGE 1

month day year

month day year
Place:

Place:
PREVIOUS MARRIAGE 2

month day year

month day year
Place:

Place:
7. DO YOU LIVE WITH YOUR SPOUSE? (If "yes", skip to Item 10, if "no", answer Items 8 and 9)
YES

NO

8. WHAT IS YOUR SPOUSE'S ADDRESS?

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

VA FORM
JAN 2020

0918b

VETERAN'S UNMARRIED CHILDREN

Note: In Items 10A through 10I, check all boxes that apply. . If you have more than six dependents that should be listed in Items 10A
through 10I, attach all applicable data for the additional dependents on a continuation sheet and submit with the VA Form 0918b.
10A.
NAME OF CHILD
(first, middle initial, last)

10B.
DATE AND PLACE OF
BIRTH
(city, state or country)

10C.
SOCIAL
SECURITY
NUMBER
(Last 4-digits only)

10D.
BIO LOGICAL

10E.
ADOPT ED

10F.
STEP CHILD

10G.
10I.
10H.
18-23 YRS.
CHILD
SERIOUSLY
OLD AND IN
PREVIOUSLY
DISABLED
SCHOOL
MARRIED

mo day yr
PLACE:

mo day yr
PLACE:

mo day yr
PLACE:

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 11A through 11C.
11A. NAME OF CHILD (First, middle initial, last)

11B. CHILD'S COMPLETE ADDRESS

11C. NAME OF PERSON THE CHILD LIVES
WITH (If applicable)

12. I hereby certify that the information given above is true and correct to the best of my knowledge and belief.
13A. SIGNATURE OF CLAIMANT (Ink signature required)

14. TELEPHONE NUMBER

VA FORM 0918b, JAN 2020, page 2

13B. DATE SIGNED

15. E-MAIL ADDRESS