State Disability- vet form.doc (w)
Name and address of Civil Service Agency: Warren County Department of Civil Service Administration
1340 State Route 9
Lake George, NY 12845
1. TO BE COMPLETED BY VETERAN
Type or print in ink, and send two copies of this form to the Department of Veterans Affairs where your
disability claim is on file.
To Chief, Veterans Benefits and Services Division , N.Y.
I hereby authorize you to furnish the above Civil Service Agency with the data requested in Section 2
below pertaining to my disability status. You are released from all liability in complying with this
request. It is understood that all information furnished will be treated as confidential.
Print Full Name V.A. Claim Number Service Number
Address Number and Title of Examination(s) for which credit is claimed
Social Security Number
Veteran’s Signature Date
2. TO BE COMPLETED BY VETERANS BENEFITS ADMINISTRATOR
Please return original to the Civil Service Agency at address indicated at top of form.
Date Claim Number Regional V.A. Office
a.
Does the above-named veteran now have a war-incurred disability? If Yes, please
enter date disability was sustained. Date:
Yes No
b. Date of VA Disability Determination:
c. State percentage of such disability now in existence. %
d.
Date of last medical examination by the V.A. Medical Officer in connection with such disability.
(If less than one year ago, do not answer e and f.) Date:
e.
Does the V.A. state affirmatively that a permanent stabilized condition of disability
exists to an extent of 10% or more, even though the veteran has not been examined
by V.A. Medical Officer within one year?
Yes No
f. Date of next scheduled medical examination by the V.A. Date:
g. Remarks
Signature of Adjudication Officer:
PERSONAL PRIVACY PROTECTION LAW NOTIFICATION
The information which you are providing on this application is being requested in accordance with section 85 of the Civil Service Law for the
principal purpose of establishing your status as a disabled veteran and processing your application for additional credit. This information will be used
in accordance with section 96(1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e), and (f). Failure to provide this information
may result in the disapproval of your application. The information will be maintained by the Municipal Civil Service Commission or Municipal
Personnel Officer administering the examination. For further information relating to the Personal Privacy Protection Law, call (518) 457-9375. If you
have a question regarding this information, you should contact the Municipal Civil Service Commission/Personnel Officer administering this
examination.
DISABILITY RECORD AUTHORIZATION
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signature
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