C.S. 295_Rev 6/02
STATE OF LOUISIANA
Department of Civil Service
P. O. Box 94111, Capitol Station
Baton Rouge, Louisiana 70804-9111
CLAIM FORM FOR VETERANS PREFERENCE FOR SPOUSE/PARENT
Veterans
: Do NOT use this form to claim veteran’s preference for yourself. Instead, submit a copy of
your DD214 and, if applicable, a copy of your Veterans’ Administration disability certification letter
attached to a copy of your application for state employment (SF-10).
ALL APPLICANTS: Only one person may receive veteran’s preference points: the veteran, the spouse of the veteran, the un-
remarried widow/widower of the veteran, OR the parent of the veteran. This form is to be used ONLY by the: spouse,
unremarried widow or widower OR parent of a disabled or deceased veteran.
With this form, you must submit a copy of the veteran’s DD214, any Veterans Administration statement of
disability, a copy of your marriage certificate, a copy of the death certificate, if applicable, and your application.
YOUR NAME (applicant): SSN:
ADDRESS: CITY: STATE: ZIP
SIGNATURE ________________________________________________________ DATE
To the best of your knowledge, has anyone else (including the veteran) claimed preference for state employment based on the
service of the veteran named below? Yes No If yes, list their names :
VETERAN INFORMATION
Name of the veteran SSN:
Branch of military service Date of entry into service:
If veteran served during peacetime only, did he/she receive a campaign badge or service ribbon? Yes No
In which campaign/action did he/she participate? _____________________________________________________________
Has veteran applied within the past twelve months for employment with the state of Louisiana? Yes No
Is the veteran deceased? Yes No If yes, the date of death
Is veteran receiving disability retirement from a branch of the armed forces? Yes No
Does veteran have existing disability recognized by Veterans Administration as service connected? Yes No
If yes, attach official statement from Veterans Administration, dated within the past 6 months, certifying disability.
Is veteran employed full-time? Yes No or part-time? Yes No Nature of employment before/after disability:
NOTE: For a spouse to receive preference, the disabled veteran must be unable to perform his/her usual occupation because of
his/her disability. A statement from the veteran’s physician certifying this must be attached to this claim form.
________________________________________________________________________________________________________
SPOUSE INFORMATION
If you are the spouse OR un-remarried widow or widower of a disabled or deceased veteran, answer these questions:
1. Date of marriage
2. Are you currently married to this veteran? Yes No If no, answer these questions:
If you are divorced from the veteran, give the date of divorce
If the veteran is deceased, were you married to him/her at the time of death? Yes No
Have you remarried? Yes No
________________________________________________________________________________
PARENT INFORMATION
If you are a parent of a disabled or deceased veteran, answer these questions:
1. Is the veteran your natural child adopted child stepchild
2. Are you still married to the veteran’s mother/father? Yes No
3. If divorced or widowed, have you remarried? Yes No
All Applicants: Please be sure you have completed all information requested in the Veteran Information box above.
