Fillable NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE (County of Fulton)

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NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE (County of Fulton)

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BROWSE COUNTY OF FULTON (NY) FORMS

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Special Circumstances
Under the special circumstances shown below, you must also submit simultaneously with your claim:
If claiming non service-connected pension with aid and attendance or housebound benefits, a completed
VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance,
and a completed VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for
Aid and Attendance;
If claiming a child in school between the ages of 18 and 23, a completed VA Form 21-674, Request for
Approval of School Attendance;
If claiming benefits for a seriously disabled (helpless) child, all, if any, relevant, private medical treatment
records for the child's pertinent disabilities.
FDC Criteria (Claim(s) for Veterans Non Service-Connected Pension Benefits)
1. Submit your claim on a signed and completed VA Form 21-527EZ, Application for Pension (attached).
2. Submit simultaneously with your claim:
All necessary income and net-worth information; AND
All, if any, relevant, private medical treatment records and an identification of any relevant
treatment records available at a Federal facility, such as a VA medical center
NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
VETERANS NON SERVICE-CONNECTED PENSION BENEFITS
VA FORM
JUN 2014
21-527EZ
Page 1
.
3. Report for any VA medical examinations VA determines are necessary to decide your claim.
.
SUPERSEDES VA FORM 21-527EZ, AUG 2011,
WHICH WILL NOT BE USED.
.
.
.
(This notice is applicable to veterans claims for: Non Service-Connected Pension • Non Service-Connected Pension with Aid and
Attendance or Housebound Benefits • Benefits Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for veterans non service-connected pension benefits.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and
there is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans non service-connected
pension benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for
veterans disability compensation or related compensation benefits, use VA Form 21-526EZ, Application for Disability
Compensation and Related Compensation Benefits. If you are making a claim for survivor benefits, use
VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits.
VA forms are available at www.va.gov/vaforms
The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!
Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are
entitled. If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your
claim, then VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard
Claim Process. See below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional
Expedited Process). If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim
Process.
WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant
evidence not in your possession..
Standard Claim Process
FDC Program (Optional Expedited Process)
You are strongly encouraged to:
• Send any information or evidence as soon as you can
You have up to one year from the date we receive the claim to
submit the information and evidence necessary to support your
claim. If we decide the claim before one year from the date we
receive the claim, you will still have the remainder of the one
year period to submit additional information or evidence
necessary to support the claim.
VA will:
• Retrieve relevant records from a Federal facility, such as
a VA medical center, that you adequately identify and
authorize VA to obtain
• Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your
claim
You must:
• If you know of evidence not in your possession and want
VA to try to get it for you, give VA enough information
about the evidence so that we can request it from the
person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure
we receive all requested records that are not in the possession
of a Federal department or agency.
VA FORM 21-527EZ, JUN 2014
Page 2
You must:
• Submit your claim in accordance with the
"FDC Criteria" (see page 1)
HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
FDC Program (Optional Expedited Process)
Standard Claim Process
WHEN YOU SHOULD SEND WHAT WE NEED
You must:
• Send the information and evidence simultaneously with
your claim
If you submit additional information or evidence after you
submit your "fully developed" claim, then VA will remove the
claim from the FDC Program Expedited Process and process
it in the Standard Claim Process. If we decide your claim before
one year from the date we receive the claim, you will still have
the remainder of the one-year period to submit additional
information or evidence necessary to support the claim.
FDC Program (Optional Expedited Process)
Standard Claim Process
WHERE TO SEND INFORMATION AND EVIDENCE
Mail or take your application and any evidence in support of your claim to the closest VA regional office. VA regional office
addresses are available on the Internet at www.va.gov/directory.
VA will:
• Retrieve relevant records from a Federal facility, such as
a VA medical center, that you adequately identify and
authorize VA to obtain
• Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your
claim
• Make every reasonable effort to obtain relevant
records not held by a Federal facility that you adequately
identify and authorize VA to obtain. These may include
records from State or local governments and privately
held evidence and information you tell us about, such as
private doctor or hospital records or records from current
or former employers
Non Service-Connected Pension with Aid and Attendance or Housebound Benefits
To support a claim for non increased disability pension benefits based on the need for aid and attendance, the evidence
must show:
• You have corrected vision of 5/200 or less in both eyes; OR
• You have contraction of the concentric visual field to 5 degrees or less; OR
• You are a patient in a nursing home due to mental or physical incapacity; OR
• You require the aid of another person in order to perform personal functions required in everyday living,
such as bathing, feeding, dressing yourself, attending to the wants of nature, adjusting prosthetic devices,
or protecting yourself from the hazards of your daily environment; OR
• You are bedridden, in that your disability requires that you remain in bed apart from any prescribed course
of convalescence or treatment
To support your claim for increased disability pension benefits based on being housebound, the evidence must show:
• You have a single permanent disability evaluated as 100 percent disabling; AND due to such disability, you are
permanently and substantially confined to your immediate premises; OR
• You have significant additional disability (rated 60% or higher) in addition to any disability necessary to establish
pension eligibility
Non Service-Connected Pension
To support a claim for non service-connected pension, the evidence must show:
1. You met certain minimum requirements regarding active service during a period of war.
Generally, those requirements involve:
• 90 days of consecutive service at least one day of which was during a period of war; OR
• 90 days of combined service during at least one period of war:
(Note: If your service began after September 7, 1980, additional length of service requirements may apply, typically
requiring two years of continuous service or completion of active-duty obligation)
• OR, any length of active service during a period of war with a discharge due to a service-connected disability
2. You are age 65 or older or are permanently and totally disabled. You are considered permanently and totally disabled
if medical evidence shows you are:
• A patient in a nursing home for long-term care; OR
• Receiving Social Security disability benefits; OR
• Unemployable due to a disability reasonably certain to continue throughout your lifetime; OR
• Suffering from a disability that is reasonably certain to continue throughout your lifetime that would make it
impossible for an average person to follow a substantially gainful occupation; OR
• Suffering from a disease or disorder that VA determines causes persons who have that disease or disorder
to be permanently and totally disabled
3. Your net worth and income do not exceed certain requirements.
Non Service-connected needs-based benefits (pension)
Increased pension benefits because your disabilities cause you to
be in need of aid and attendance or to be confined to your residence
Benefits because your child is severely disabled
Helpless Child
Non Service-Connected Pension with Aid and Attendance
or Housebound Benefits
VA FORM 21-527EZ, JUN 2014
Page 3
WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
EVIDENCE TABLES
See the evidence table titled...
Non Service-Connected Pension
If you are claiming...
IMPORTANT
If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you
and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later
datewhen you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognized marriages is available
at http://www.va.gov/opa/marriage/.
For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/.
For more information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the number is 711.
VA forms are available at www.va.gov/vaforms.
Helpless Child
To support a claim for benefits based on a veteran's child being helpless, the evidence must show that the child, before his or her
18th birthday, became permanently incapable of self-support due to a mental or physical disability.
If you wish to make a claim for veterans disability compensation and/or related compensation benefits, use VA Form 21-526EZ,
Application for Disability Compensation and Related Compensation Benefits. VA forms are available at www.va.gov/vaforms.
If you cannot access this form, write the words "Will claim compensation - send VA Form 21-526EZ" under Item 9 or at the top of
the attached application and VA will send you the form.
IMPORTANT
How VA Determines the Effective Date
If we grant your claim, the beginning date of your entitlement will generally be based on when we received your claim.
Higher levels of non service-connected pension may be assigned for disabilities that affect your ability to perform certain activities of
daily living or the ability to leave your home. Higher levels of pension may be effective from the date the medical evidence first
shows entitlement.
EVIDENCE TABLES (Continued)
Page 4
VA FORM 21-527EZ, JUN 2014
10. LIST ANY VA MEDICAL CENTERS WHERE YOU RECEIVED TREATMENT FOR YOUR
CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES
A. DISABILITY(IES)
B. DATE(S) OF TREATMENT
4. SEX
12E. PLACE OF LAST OR ANTICIPATED SEPARATION
3. DATE OF BIRTH (MM,DD,YYYY) 2. SOCIAL SECURITY NUMBER
APPLICATION FOR PENSION
OMB Control No. 2900-0747
Respondent Burden: 25 minutes
Expiration Date: 4/30/2016
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 8 before completing the form.
SECTION I: VETERAN'S PERSONAL INFORMATION (MUST COMPLETE)
7A. MAILING ADDRESS
5. HAVE YOU EVER FILED A CLAIM WITH VA?
(If "Yes," provide your file number in Item 6)
City State ZIP Code Country
Street address, rural route, or P.O. Box Apt. number
CELL PHONE
( )
EVENING
( )
( )
7B. TELEPHONE NUMBERS (Include Area Code)
16C. LIST TYPE (If known)
8A. PREFERRED E-MAIL ADDRESS (If applicable)
6. VA FILE NUMBER
8B. ALTERNATE E-MAIL ADDRESS (If applicable)
( )
11A. DID YOU SERVE UNDER ANOTHER NAME?
11B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER
14A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?
(If "No," skip to Item 12A)
(If "Yes," complete Item 11B)
12A. I ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
13A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
AUTHORITY OF TITLE 10, U.S.C. (National Guard)?
14B. WHAT IS THE TELEPHONE NUMBER OF
YOUR CURRENT UNIT? (Include Area Code)
(If "Yes," provide date of activation in Item 13B)
13B. DATE OF ACTIVATION (MM,DD,YYYY)
16A. DID YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE
RETIRED PAY?
12C. RELEASE DATE OR ANTICIPATED DATE
OF RELEASE FROM ACTIVE SERVICE
12B. BRANCH OF SERVICE
SECTION III: VETERAN'S WORK HISTORY (MUST COMPLETE)
12D. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?
1. VETERAN'S NAME (Last, first, middle)
15B. DATES OF CONFINEMENT ON (MM,DD,YYYY)
15A. HAVE YOU EVER BEEN A PRISONER OF WAR?
(If "No," skip to Item 16A)
(If "Yes," complete Items 16B and 16C)
9. WHAT DISABILITY(IES) PREVENTS YOU FROM WORKING?
(If "Yes," complete Item 15B)
A. NAME AND LOCATION OF VA MEDICAL CENTER
SUPERSEDES VA FORM 21-527EZ, AUG 2011,
WHICH WILL NOT BE USED.
Page 5
VA FORM
JUN 2014
21-527EZ
B. DATE DISABILITY(IES) BEGAN
DAYTIME
16B. LIST AMOUNT (If known)
NOTE: In the table below, tell us about all of your employment, including self-employment, for one year before you became disabled to the present.
SECTION II: VETERAN'S SERVICE INFORMATION (MUST COMPLETE)
17F. WHAT WERE
YOUR TOTAL
ANNUAL EARNINGS?
17A. WHAT WAS THE NAME AND ADDRESS OF
YOUR EMPLOYER?
17B. WHAT WAS
YOUR JOB TITLE?
17C. WHEN DID
YOUR JOB BEGIN?
17D. WHEN DID
YOUR JOB END?
$
17E. HOW MANY
DAYS WERE LOST
DUE TO DISABILITY?
$
$
MALE
FEMALE
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
From:
To:
YES
NO
(Skip to Section VI if never married)
(If "Yes," skip to Section VI)
(Check all that apply)
22H. HOW MUCH DO YOU CONTRIBUTE MONTHLY TO YOUR
SPOUSE'S SUPPORT?
VA FORM 21-527EZ, JUN 2014
TELL US ABOUT YOUR SPOUSE'S MARRIAGE/PREVIOUS MARRIAGES
22B. WHAT IS YOUR SPOUSE'S
SOCIAL SECURITY NUMBER?
20. HOW MANY TIMES HAS YOUR SPOUSE BEEN MARRIED (including current marriage)?
(If "No," complete Items 22F - 22H)
SECTION V: CURRENT MARITAL INFORMATION (COMPLETE ONLY IF YOU ARE CURRENTLY MARRIED)
22D. WHAT IS YOUR SPOUSE'S VA
FILE NUMBER (if any)?
Page 6
22C. IS YOUR SPOUSE
ALSO A VETERAN?
18A. WHAT IS YOUR MARITAL STATUS? (Check one)
SECTION VI: DEPENDENT CHILDREN (COMPLETE IF YOU HAVE DEPENDENT CHILDREN)
Note - In Items 24A through 24D, tell us about the children listed in Item 23A who do not live with you.
19F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 19C, PLEASE EXPLAIN:
23G.
18-23 YEARS
OLD (in school)
24B. CHILD'S COMPLETE ADDRESS
(Number and street or rural route, city or P.O., city,
State, ZIP Code and country)
23C. SOCIAL
SECURITY
NUMBER
TELL US ABOUT YOUR MARRIAGE/PREVIOUS MARRIAGES
18B. HOW MANY TIMES HAVE YOU BEEN MARRIED (including current marriage)?
23D.
BIOLOGICAL
19A. DATE (month, day, year) AND PLACE OF
MARRIAGE (city/state or country)
19E. DATE (month, day,
year) AND PLACE
MARRIAGE TERMINATED
(city/state or country)
19B. TO WHOM
MARRIED
(first, middle, last name)
19C. TYPE OF MARRIAGE
(ceremonial, common-law,
proxy, tribal, or other)
19D. HOW MARRIAGE
TERMINATED
(death, divorce, marriage has not
been terminated)
22F. WHAT IS YOUR SPOUSE'S ADDRESS? (Number and street or rural route, city or P.O.,
State, ZIP Code and country)
22A. WHAT IS YOUR SPOUSE'S DATE OF
BIRTH? (month, day, year)
22E. DO YOU LIVE WITH YOUR SPOUSE?
22G. TELL US THE REASON WHY YOU ARE NOT LIVING WITH YOUR SPOUSE
(i.e.; illness, work, etc.)
$
23H.
SERIOUSLY
DISABLED
SECTION IV: MARITAL STATUS (MUST COMPLETE)
Note - Skip to Section VI if not currently married.
23F.
STEPCHILD
23I.
CHILD
MARRIED
23J. CHILD
PREVIOUSLY
MARRIED
21F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 21C, PLEASE EXPLAIN:
21A. DATE (month, day, year) AND PLACE OF
MARRIAGE (city/state or country)
21E. DATE (month, day,
year) AND PLACE
MARRIAGE TERMINATED
(city/state or country)
21B. TO WHOM
MARRIED
(first, middle, last name)
21C. TYPE OF MARRIAGE
(ceremonial, common-law,
proxy, tribal, or other)
21D. HOW MARRIAGE
TERMINATED
(death, divorce, marriage has not
been terminated)
23E.
ADOPTED
Note - Skip to Section VII if you have no dependent children.
24A. NAME OF DEPENDENT CHILD
(First, middle initial, last)
23A. NAME OF DEPENDENT
CHILD
(First, middle initial, last)
23B. DATE AND
PLACE OF BIRTH
(city, state or country)
24D. MONTHLY AMOUNT YOU
CONTRIBUTE TO THE CHILD'S
SUPPORT
24C. NAME OF PERSON THE CHILD
LIVES WITH (If applicable)
$
$
$
NEVER MARRIED MARRIED WIDOWED DIVORCED
YES
NO
YES
NO
27. EXPECTED INCOME - NEXT 12 MONTHS (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")
BLACK LUNG
BENEFITS
U.S. RAILROAD
RETIREMENT
U.S. CIVIL SERVICE
SOCIAL SECURITY
SOURCE
STOCKS, BONDS,
MUTUAL FUNDS, ETC.
INTEREST-BEARING
BANK ACCOUNTS
IRA'S, KEOGH PLANS,
ETC.
CASH/NON-INTEREST
BEARING BANK
ACCOUNTS
RECIPIENT
Report total monthly income for your household. You must report your income and the income of your dependents (spouse, child, etc.), if any. Identify
the specific income recipient for each income source, yourself or another person in your household, as applicable.
OWNER
SECTION IX: EXPECTED INCOME (MUST COMPLETE)
SECTION VIII: INCOME VERIFICATION - MONTHLY INCOME (MUST COMPLETE
)
Report total net worth for your household. You must report your net worth and the net worth of your dependents (spouse, child, etc.), if any. Identify the
specific owner for each net worth source, yourself or another person in your household, as applicable.
25. NET WORTH (DO NOT LEAVE ANY ITEMS BLANK. If your household has no net worth in a particular source, write "0" or "none")
SECTION VII: INCOME VERIFICATION - NET WORTH (MUST COMPLETE)
RECIPIENT
Report expected total household income for the next 12 months. You must report your expected income and the expected income of your dependents
(spouse, child, etc.), if any. Identify the specific income recipient for each income source, yourself or another person in your household, as applicable.
SECTION X: MEDICAL, LEGAL, OR OTHER UNREIMBURSED EXPENSES (MUST COMPLETE)
28. MEDICAL, LEGAL, OR OTHER UNREIMBURSED EXPENSES (IF NONE WRITE "0" OR "NONE")
RELATIONSHIP OF PERSON
FOR WHOM EXPENSES PAID
(Spouse, child, etc.)
26. GROSS MONTHLY INCOME (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")
VA FORM 21-527EZ, JUN 2014
Page 7
PURPOSE
(Doctor's fees, hospital charges, attorney fees, tuition,
education materials, etc.)
AMOUNT
$
GROSS WAGES AND
SALARY
PAID TO (Name of doctor,
hospital, pharmacy, etc.)
Report your family medical expenses and certain other expenses actually paid by you that may be deductible from your income. Show
the amount of unreimbursed medical expenses, including the Medicare deduction you paid for yourself or relatives who are members of
your household. Also, show unreimbursed last illness and burial expenses and educational or vocational rehabilitation expenses you
paid. Last illness and burial expenses are unreimbursed amounts paid by you for the last illness and burial of a spouse or child at any
time prior to the end of the year following the year of death. Educational or vocational rehabilitation expenses are amounts paid for
courses of education, including tuition, fees, and materials. Show medical, legal or other expenses you paid because of a disability for
which civilian disability benefits have been awarded. When determining your income, we may be able to deduct them from the disability
benefits for the year in which the expenses are paid. Do not include any expenses for which you were reimbursed.
REAL PROPERTY
(Not your home, vehicle,
furniture, or clothing)
ALL OTHER PROPERTY
(Please write source)
SOURCERECIPIENTSOURCE
$
$
TOTAL DIVIDENDS AND
INTEREST
AMOUNT
ALL OTHER PROPERTY
(Please write source)
$
AMOUNT PAID BY YOU
DATE PAID
(mm/dd/yy)
$
$
GROSS WAGES AND
SALARY
OTHER (Provide source)
OTHER (Provide source)
OTHER INCOME
EXPECTED (Provide source)
$
$
$
$
$
OTHER (Provide source)
OTHER (Provide source)
$
OTHER INCOME
EXPECTED (Provide source)
OTHER INCOME
EXPECTED (Provide source)
AMOUNT SOURCERECIPIENT
SUPPLEMENTAL SECURITY
INCOME (SSI)/PUBLIC
ASSISTANCE
SOCIAL SECURITY
AMOUNT
$
$
SERVICE RETIREMENT
$
$
$
OWNER SOURCE AMOUNTSOURCE AMOUNT
$
$
$
$
$
$
$
$
$
$
$
SECTION XI: DIRECT DEPOSIT INFORMATION (MUST COMPLETE)
32. The FDC Program is designed to rapidly process compensation or pension claims received with the evidence necessary to decide the claim. VA will
automatically consider a claim submitted on this form for rapid processing under the FDC Program. Check the below box ONLY if you DO NOT want
your claim considered for rapid processing under the FDC Program because you plan to submit further evidence in support of your claim.
I DO NOT want my claim considered for rapid processing under the FDC Program because I plan to submit further evidence in support of my
claim.
35B. PRINTED NAME AND ADDRESS OF WITNESS
PRIVACY ACT NOTICE: The form will be used to determine allowance to pension benefits (38 U.S.C. 5101). The responses you submit are considered
confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is
authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education,
and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. The requested information is considered relevant and
necessary to determine maximum benefits under the law. Information submitted is subject to verification through computer matching programs with other
agencies. VA may make a "routine use" disclosure for: 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. Your obligation to respond is required in order to
obtain or retain benefits. Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the
purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in
any benefit program administered by the Department of Veterans Affairs. Social Security information: You are required to provide the Social Security
number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may
disclose them for purposes stated above.
SECTION XIII: WITNESSES TO SIGNATURE (MUST COMPLETE ONLY IF VETERAN SIGNED ITEM 33A WITH AN "X")
34A. SIGNATURE OF WITNESS (If veteran signed above using an "X")
35A. SIGNATURE OF WITNESS (If veteran signed above using an "X")
33B. DATE SIGNED
34B. PRINTED NAME AND ADDRESS OF WITNESS
33A. VETERAN'S SIGNATURE (REQUIRED)
VA FORM 21-527EZ, JUN 2014
RESPONDENT BURDEN: We need this information to determine your eligibility for pension. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 25 minutes to review the instructions, find the information, and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of
information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/
PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
29. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA.)
The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit.
Please attach a voided personal check or deposit slip or provide the information requested below in Items 29, 30, and 31 to enroll in direct
deposit. If you do not have a bank account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct
Express Debit MasterCard you must apply at www.usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to enroll, you must
contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They will encourage your participation in
EFT and address any questions or concerns you may have.
SECTION XII: CLAIM CERTIFICATION AND SIGNATURE (MUST COMPLETE)
31. ROUTING OR TRANSIT NUMBER (The first nine numbers located
at the bottom left of your check)
30. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank where
you want your direct deposit)
Page 8
I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I
authorize any person or entity, including but not limited to any organization, service provider, employer, or government agency, to give the Department of
Veterans Affairs any information about me and I waive any privilege which makes the information confidential.
I certify I have received the notice attached to this application titled Notice to Veteran of Evidence Necessary to Substantiate a Claim for
Veterans Non-Service Connected Pension Benefits.
I certify I have enclosed all the information or evidence that will support my claim, to include an identification of relevant records available at a Federal
facility, such as a VA medical center; OR, I have no information or evidence to give VA to support my claim; OR, I have checked the box in Item 32,
indicating that I do not want my claim considered for rapid processing in the Fully Developed Claim (FDC) Program because I plan to submit further
evidence in support of my claim.
Account No.:__________________
Account No.:__________________
SAVINGSCHECKING
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL
INSTITUTION OR CERTIFIED PAYMENT AGENT
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NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE (County of Fulton)

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Completed 13 February 2021

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