Fillable Centralized Intake Coversheet (City of Oakland)

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Centralized Intake Coversheet (City of Oakland)

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USE THIS COVER SHEET TO SEND CLAIM MATERIALS TO THE VA CLAIMS INTAKE CENTER
*** EFFECTIVE JANUARY 2017 – PLEASE DO NOT USE PREVIOUS VERSIONS***
Centralized Intake Coversheet
To: Department of Veterans Affairs Claims Intake Center
PO BOX 4444, Janesville, WI 53547-4444
Fax: 844-531-7818
Claimant Last Name:
Claimant First Name:
Claimant C-File #:
Claimant Zip Code:
VSO Contact Email:
Fax Date (MM/DD/YYYY – if applicable):
# of
Pages to Include Coversheet:
Emergent Claim Categories (if applicable)
"TERM" Terminally ill claimants
"SERW" Veterans seriously injured in
service but not in receipt of benets
"FINH" Claimants suering from
extreme nancial hardship
"FPOW" Former prisoners of war and their
survivors
"HOME" Homeless Veterans
"SUIC" Suicidal claimants
"ALS" Diagnose with Amyotrophic Lateral
Sclerosis (ALS) or Lou Gehrig’s Disease
"AGE" Greater than 85 years of age
"HONR" Awarded the Medal of Honor
Visually Impaired Veteran
List Forms Included:
00381 VA 21-0781 Statement in Support of Claim for Service
Connection for Post-Traumatic Stress Disorder (PTSD)
00295 VA 21-22 Appointment of Veterans Serv. Org.
00111 VA 21-2680 Request for Aid and Attendance /
Housebound Status
00115 VA 21-4138 Statement In Support of Claim
00386 VA 21-4140-1 Employment Questionnaire
00131 VA 21-526 Veterans Application for Compensation
00532 VA 21-526b, Veteran Supplemental Claim
00533 VA 21-526EZ, Fully Developed Claim (Compensation)
00142 VA 21-674 Request for Approval of School Attendance
00148 VA 21-686c Declaration of Status of Dependents
00158 VA 21-8940 Veteran's Application for Increased
Compensation Based of Unemployability
00173 VA 572 Request for Change of Address / Cancellation
00420 DD 214 Certied Original - Certicate of Release
00025 Birth Certicate
00091 Divorce Decree
00061 Marriage Certicate / License
Other:
IMPORTANT: Verify on Fax Confirmation Sheet the Claims Evidence is sent to
844-531-7818
Disclaimer: VA Directive 6609, “Mailing of Sensitive Personal Information,” dated May 20, 2011 states that access to
Veterans’ records is limited to authorized persons only. Information may not be disclosed from this file unless permitted
by all applicable legal authorities, enforced by 38 C.F.R. §§ 1.460 – 1.599 and 45 C.F.R. Parts 160 and 164. The Privacy
Act contains provisions for criminal penalties for knowingly and willfully disclosing information from the Veterans’ file
unless properly authorized to do so.
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Centralized Intake Coversheet (City of Oakland)

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Completed 21 September 2020

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