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

OMB Approved No. 2900-0094
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

SUPPLEMENT TO VA FORMS 21-526EZ, 21P-534EZ, AND 21P-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)

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

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

3. VA FILE NUMBER

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
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

8. RELATIONSHIP TO VETERAN (Self, Spouse, Child, Parent)

9. FULL MAIDEN NAME OF CLAIMANT'S MOTHER

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

MARINE CORPS

COAST GUARD

SPACE FORCE

OTHER (Specify)
11A. ENTERED SERVICE
DATE (MM/DD/YYYY)

11B. SERVICE NUMBER

11C. SEPARATED FROM SERVICE
DATE (MM/DD/YYYY)

PLACE

11D. GRADE AND ORGANIZATION

PLACE

PHILIPPINE ARMY
12A. ENTERED SERVICE
DATE (MM/DD/YYYY)

12B. SERVICE NUMBER

12C. SEPARATED FROM SERVICE
DATE (MM/DD/YYYY)

PLACE

PLACE

12F.
12D.
12E.
12G.
DIVISION REGIMENT COMPANY RANK

GUERILLA ORGANIZATION
13A. ENTERED SERVICE
DATE (MM/DD/YYYY)

VA FORM
XXX XXXX

21-4169

13B. SERVICE NUMBER

13C. NAME OF ORGANIZATION

PLACE

SUPERSEDES VA FORM 21-4169, MAR 2018.

13D.
13E.
13F.
13G.
DIVISION REGIMENT COMPANY RANK

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

NO

14C. PLACE OF EXAMINATION (Address)

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

NO

NO

15B. MILITARY CHARGES

(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?
YES

14B. DATE EXAMINED (MM/DD/YYYY)

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

AFFIDAVITS ATTACHED

(If "Yes," complete Item 16B)

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
HOSPITALIZATION OR
DOMICILIARY CARE FROM THE
PHILIPPINE GOVERNMENT OR
ANY OF ITS SUBDIVISIONS?
YES

NO

18B. DATE
ENTERED
INSTITUTION
(MM/DD/YYYY)

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

18D. NAME AND ADDRESS OF INSTITUTION

(If "Yes," complete
Items 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?
YES

NO

(If "Yes," complete Items 20B and 21) (If "NO," skip to Item 22)

20B. ORGANIZATIONS (Check all boxes that apply)
MAKAPILI

PAMPAR

SAKDAL
GANAP
MORISITA
BUTAI

SHIN
NICHI TAI

YOIN

MATSUYAMA
BUTAI

PEACE ARMY

SAKDAL

JAPANESE-FILIPINO
BROTHERHOOD ASSN.

HIRATA-TAI

GANAP

NEW UNITY

NEW LEADERS
ASSOCIATION

OTHER PRO-JAPANESE OR PRO-GERMAN OR
ANTI-AMERICAN-FILIPINO ORGANIZATIONS

(Specify each below)

STANDING ARMY OF
THE PHILIPPINES

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

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

NO

(If "YES," complete Item 21B)

VA FORM 21-4169, XXX XXXX

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

MUNICIPAL POLICE FORCE

MANILA DEFENSE CORPS

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

NO

22B. GIVE DETAILS

(If "YES," complete Item 22B)

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

NO

22E. STATE HOW AND BY WHOM

(If "YES," complete Item 22E)

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

NO

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

YOU WERE REGARDED
AS AWOL

NO

YOU WERE PUNISHED
FOR LEAVING

23B. WHY NOT?

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

YOU RETURNED OF YOUR
OWN FREE WILL

(If "YES," complete Item 23B)

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)

25B. NAME OF ACCUSING AGENCY
25D. DATE ACCUSED (MM/DD/YYYY)

25C. NAME OF PERSON ACCUSED
25E. PLACE

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)

PHILIPPINE GOVERNMENT BENEFITS
26B.

AMOUNT OF SETTLEMENT

DATE (MM/DD/YYYY)

CLAIM NO.

OFFICE WITH WHICH FILED

AMOUNT OF PENSION

DATE (MM/DD/YYYY)

CLAIM NO.

OFFICE WITH WHICH FILED

ARREARS IN PAY (back pay)
FROM PHIL COM
26C.
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.
27E. PLACE OF RESIDENCE DURING EXISTENCE OF THIS RELATIONSHIP

27D. BEGINNING DATE OF THIS RELATIONSHIP (MM/DD/YYYY)

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

NO

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

DATE OF BIRTH (MM/DD/YYYY)

PLACE OF BIRTH

28. REMARKS

SECTION VI - CERTIFICATION
I HEREBY CERTIFY THAT I
(have read)
(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.
29A SIGNATURE OF CLAIMANT (Required) (If claimant can write, then they must sign their name. If claimant

29B. DATE

cannot write then affix thumbprint which must be witnessed by two persons who can write.)

Month

Day

Year

WITNESS TO THUMBPRINT
30A.PRINT NAME (First-Middle Initial-Last) AND ADDRESS OF WITNESS NUMBER 1

30B. SIGNATURE OF WITNESS (Sign in ink)

30C. DATE (MM/DD/YYYY)

31A. PRINT NAME (First-Middle Initial-Last) AND ADDRESS OF WITNESS NUMBER 2

31B. SIGNATURE OF WITNESS (Sign in ink)

31C. DATE (MM/DD/YYYY)

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 is false, or for fraudulent receipt of any payment to which you are not entitled.
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, Veteran Readiness 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project is 2900-0094, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected] Please refer to OMB
Control No. 2900-0094 in any correspondence. Do not send your completed VA Form 21-4169 to this email address.
VA FORM 21-4169, XXX XXXX

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