Fillable NOTICE TO VETERAN/SERVICE MEMBER OF EVIDENCE NECESSARY TO (City of North Reading)

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NOTICE TO VETERAN/SERVICE MEMBER OF EVIDENCE NECESSARY TO (City of North Reading)

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Special Circumstances
Under the special circumstances shown below, you must also submit simultaneously with your claim:
• For National Guard and Reserve members, any and all Service Treatment and Personnel Records in the custody of your
Unit(s)
• If claiming dependents, a completed VA Form 21-686c, Declaration of Status of Dependents. If claiming a child in school
between the ages of 18 and 23, you must also submit a completed VA Form 21-674, Request for Approval of School
Attendance. If claiming benefits for a seriously disabled (helpless) child, you must also submit all, relevant, private medical
treatment records pertaining to the child's pertinent disabilities
• If claiming Individual Unemployability, a completed VA Form 21-8940, Veteran's Application for Increased Compensation
Based on Unemployability, and a completed VA Form 21-4192, Request for Employment Information in Connection with
Claim for Disability Benefits
• If claiming Post-Traumatic Stress Disorder (PTSD), a completed VA Form 21-0781, Statement in Support of Claim for
Service Connection for Post-Traumatic Stress Disorder, or if claiming PTSD based on personal assault, a completed VA
Form 21-0781a, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder Secondary to
Personal Assault
• If claiming Specially Adapted Housing or Special Home Adaptation, a completed VA Form 26-4555, Application in
Acquiring Specially Adapted Housing or Special Home Adaptation Grant
• If claiming Auto Allowance, a completed VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive
Equipment
• If claiming additional benefits because you or your spouse require Aid and Aid Attendance, a completed VA Form
21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, or if claiming Aid and
Attendance based on nursing home attendance, a VA Form 21-0779, Request for Nursing Home Information in Connection
with Claim for Aid and Attendance
FDC Criteria (Claim(s) for Veterans Disability Compensation and Related Compensation Benefits)
1. Submit your claim on a signed and completed VA Form 21-526EZ, Application for Disability Compensation and Related
Compensation Benefits (Attached).
2. Submit simultaneously with your claim:
• 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.
3. Report for any VA medical examinations that VA determines are necessary to decide your claim.
(This notice is applicable to claims for: Disability Service Connection • Secondary Service Connection • Increased Disability Compensation •
Temporary Total Disability Rating • Individual Unemployability • Compensation under 38 U.S.C. 1151 • Special Monthly Compensation •
Specially Adapted Housing/Special Home Adaptation • Automobile Allowance/Adaptive Equipment • Benefits Based on a Veteran's Seriously
Disabled Child)
Use this notice and the attached application to submit a claim for veterans disability compensation and related compensation benefits. This notice
informs you of the evidence necessary to substantiate your claim. After you submit your claim, you will not receive an initial letter regarding your claim.
You do not need to resubmit another application.
May I apply electronically? You can apply for VA disability compensation and pension online through eBenefits at www.ebenefits.va.gov
. For
disability compensation claims, you can also upload all supporting evidence you may have and make your claim a Fully Developed Claim. To file a
claim for VA disability compensation electronically, go to eBenefits, select Apply for Benefits and then Apply for Disability Compensation. You will
need to create an eBenefits account to apply for disability compensation online. To file a claim for VA pension electronically, go to eBenefits, select
Apply for Benefits, and then select Apply for Veterans Benefits via VONAPP. Once you submit your claim, you can track the status using eBenefits.
NOTE: You can contact an accredited Veteran Service Officer to assist you with your application.
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 disability compensation or related compensation benefits, simply
submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for veterans non service-connected pension benefits,
use VA Form 21-527EZ, Application for Pension. 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
.
NOTICE TO VETERAN/SERVICE MEMBER
OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR VETERANS DISABILITY
COMPENSATION AND RELATED COMPENSATION BENEFITS
VA FORM
FEB 2016
21-526EZ
Page 1
SUPERSEDES VA FORM 21-526EZ, MAY 2015,
WHICH WILL NOT BE USED.
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 the VA information sufficient to enable it to obtain all relevant evidence not in
your possession. If your claim involves a disability that you had before entering service and that was made worse by service, please provide any
information or evidence in your possession regarding the health condition that existed before your entry into service.
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.
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
• 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 from current or
former employers
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
VA FORM 21-526EZ, FEB 2016
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.
For adapting and/or purchasing a residence
To support a claim for service connection based upon a period of active duty for training, the evidence must show:
• You were disabled during active duty for training due to disease or injury incurred or aggravated in the line of duty; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent
symptoms of disability that are visible or observable; AND
• There is a relationship between your current disability and the disease or injury incurred or aggravated during active duty for training. This may
be shown by medical records or medical opinions or, in certain cases, by lay evidence.
You have a disability that was caused or aggravated by your service
Your service connected disability caused or aggravated an additional
disability
Your service connected disability has worsened
Your service connected disability caused you to be hospitalized or to
undergo surgery or other treatment
Your service connected disability(ies) prevents you from getting or
keeping substantial employment
You have a disability caused or aggravated by VA medical treatment,
vocational rehabilitation, or compensated work therapy
Your service connected disability(ies) causes you to be in need of aid and
attendance or to be confined to your residence
Disability Service Connection
To support a claim for service connection, the evidence must show:
• You had an injury in service, or a disease that began in or was made permanently worse during service, or there was an event in service that
caused an injury or disease; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent
symptoms of disability that are visible or observable; AND
• A relationship exists between your current disability and an injury, disease, symptoms, or event in service. This may be shown by medical
records or medical opinions or, in certain cases, by lay evidence.
However, under certain circumstances, VA may presume that certain current disabilities were caused by service, even if there is no specific
evidence proving this in your particular claim. The cause of a disability is presumed for the following veterans who have certain diseases:
• Former prisoners of war;
• Veterans who have certain chronic or tropical diseases that become evident within a specific period of time after discharge from service;
• Veterans who were exposed to ionizing radiation, mustard gas, or Lewisite while in service;
• Veterans who were exposed to certain herbicides, such as by serving in Vietnam; or
• Veterans who served in the Southwest Asia theater of operations during the Gulf War.
VA FORM 21-526EZ, FEB 2016
Page 3
WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
To support a claim for service connection based upon a period of inactive duty training, the evidence must show:
• You were disabled during inactive duty training due to an injury incurred or aggravated in the line of duty or an acute myocardial infarction,
cardiac arrest, or cerebrovascular accident during inactive duty training; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent
symptoms of disability that are visible or observable; AND
• There is a relationship between your current disability and your inactive duty training. This may be shown by medical records or medical
opinions or, in certain cases, by lay evidence.
EVIDENCE TABLES
See the evidence table titled...
Disability Service Connection
If you are claiming...
Secondary Service Connection
Temporary Total Disability Rating
Individual Unemployability
Compensation Under 38 U.S.C. 1151
Special Monthly Compensation
Increased Disability Compensation
See the evidence table titled...
Special Adapted Housing or Special Home Adaptation
If you are claiming benefits...
Auto Allowance
Helpless Child
For adapting and/or purchasing a vehicle
Because your spouse is severely disabled
Because your child is severely disabled
Special Monthly Compensation
IMPORTANT: If you are claiming homelessness see page 6 of the Instructions for more information on expediting claims for homeless veterans.
Temporary Total Disability Rating
In order to support a claim for a temporary total disability rating due to hospitalization, the evidence must show:
• You were treated for more than 21 days for a service-connected disability at a VA or other approved hospital; OR
• You underwent hospital observation at VA expense for a service-connected disability for more than 21 days.
In order to support a claim for a temporary total disability rating due to surgical or other treatment performed by a VA or other approved
hospital or outpatient facility, the evidence must show:
• The surgery or treatment was for a service-connected disability; AND
• The surgery required convalescence of at least one month; OR
• The surgery resulted in severe postoperative residuals, such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic
immobilizations, house confinement, or the required use of a wheelchair or crutches; OR
• One major joint or more was immobilized by a cast without surgery.
Increased Disability Compensation
If VA previously granted service connection for your disability and you are seeking an increased evaluation of your service-connected disability,
we need medical or lay evidence to show a worsening or increase in severity and the effect that worsening or increase has on your ability to work.
Individual Unemployability
In order to support a claim for a total disability rating based on individual unemployability, the evidence must show:
• That your service-connected disability or disabilities are sufficient, without regard to other factors, to prevent you from performing the mental
and/or physical tasks required to get or keep substantially gainful employment; AND
• Generally, you meet certain disability percentage requirements as specified in 38 Code of Federal Regulations 4.16 (i.e. one disability ratable at
60 percent or more, OR more than one disability with one disability ratable at 40 percent or more and a combined rating of 70 percent or more).
In order to support a claim for an extra-schedular evaluation based on exceptional circumstances, the evidence must show:
• That your service-connected disability or disabilities present such an exceptional or unusual disability picture, due to such factors as marked
interference with employment or frequent periods of hospitalization, that application of the regular schedular standards is impractical.
Disability Service Connection (Continued)
In order to reopen a claim previously denied by VA, we need new and material evidence. New and material evidence must raise a reasonable
possibility of substantiating your claim. The evidence cannot simply be repetitive or cumulative of the evidence we had when we previously decided
your claim. VA will make reasonable efforts to help you obtain currently existing evidence. However, we cannot provide a medical examination or
obtain a medical opinion until your claim is successfully reopened.
• To qualify as new, the evidence must currently exist and be submitted to VA for the first time.
• In order to be considered material, the additional existing evidence must pertain to the reason your claim was previously denied.
Secondary Service Connection
To support a claim for compensation based upon an additional disability that was caused or aggravated by a service-connected disability, the
evidence must show:
• You currently have a physical or mental disability shown by medical evidence or by lay evidence of persistent and recurrent symptoms of
disability that are visible or observable, in addition to your service-connected disability; AND
• Your service-connected disability either caused or aggravated your additional disability. This may be shown by medical records or medical
opinions or, in certain cases, by lay evidence. However, VA may presume service-connection for cardiovascular disease developing in a
claimant with certain service-connected amputation(s) of one or both lower extremities.
EVIDENCE TABLES (Continued)
Compensation Under 38 U.S.C. 1151
In order to support a claim for compensation under 38 U.S.C. 1151, the evidence must show that, as a result of VA hospitalization, medical or
surgical treatment, examination, or training, you have:
• An additional disability or disabilities; OR
• An aggravation of an existing injury or disease; AND
• The disability was the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment, or not a reasonably
expected result or complication of the VA care or treatment; OR
• The direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy program.
VA FORM 21-526EZ, FEB 2016
Page 4
Specially Adapted Housing or Special Home Adaptation
To support your claim for specially adapted housing (SAH), the evidence must show you are a:
• Veteran entitled to compensation under 38 U.S.C. Chapter 11 for a permanent and totally disabling qualifying condition; OR
• Service member on active duty who has a permanent and totally disabling qualifying condition incurred or aggravated in the line of duty.
To support that you have a qualifying condition for SAH the evidence must show:
• Amyotrophic lateral sclerosis (ALS); OR
• Loss (amputation) or loss of use of
• both lower extremities; OR
• one lower extremity and one upper extremity affecting balance or propulsion; OR
• one lower extremity plus residuals of organic disease or injury affecting balance or propulsion creating a need for regular, constant use of a
wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other methods may be occasionally
possible); OR
• Loss or loss of use of both upper extremities precluding use of the arms at or above the elbow; OR
• Blindness in both eyes, with light perception only and the loss or loss of use of one lower extremity; OR
• A severe burn injury, meaning full thickness or subdermal burns that have resulted in contractures with limitation of motion of
• two or more extremities; OR
• at least one extremity and the trunk.
To support your claim for SAH the evidence may alternatively show you are a:
• Veteran who served and became permanently disabled from a qualifying condition on or after September 11, 2001; OR
• Service member on active duty who was permanently disabled in the line of duty from a qualifying condition on or after the same date.
To support that you have a qualifying condition under the alternative service criteria the evidence must show:
• Loss (amputation) or loss of use of
• one or more lower extremities, severely affecting the functions of balance or propulsion and creating a need for regular, constant use of a
wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other methods may be occasionally
possible).
To support your claim for a special home adaptation (SHA) grant the evidence must show you are a:
• Veteran entitled to compensation under 38 U.S.C. Chapter 11 for a qualifying condition; OR
• Service member on active duty who has a qualifying condition incurred or aggravated in the line of duty.
Special Monthly Compensation
In order to support a claim for increased benefits based on the need for aid and attendance, the evidence must show that, due to your service-
connected disability or disabilities:
• 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 (38
Code of Federal Regulation 3.352(a)); OR
• You are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed course of convalescence or
treatment (38 Code of Federal Regulation 3.352(a)).
In order to support a claim for increased benefits based on an additional disability or being housebound, the evidence must show:
• You have a single service-connected disability evaluated as 100 percent disabling AND an additional service-connected disability, or
disabilities, evaluated as 60 percent or more disabling; OR
• You have a single service-connected disability evaluated as 100 percent disabling AND, due solely to your service-connected disability or
disabilities, you are permanently and substantially confined to your immediate premises.
In order to support a claim for increased benefits based on your spouse's need for aid and attendance, per the provisions of 38 C.F.R. § 3.351(c),
the evidence must show:
• Your spouse is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual
field to 5 degrees or less; OR
• Your spouse is a patient in a nursing home because of mental or physical incapacity; OR
• Your spouse requires the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding,
dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the hazards of his or her daily environment
(See 38 C.F.R. § 3.352(a) for complete explanation).
IMPORTANT: For additional benefits to be payable for a spouse, the veteran must be entitled to compensation and evaluated as 30 percent or more
disabling.
VA FORM 21-526EZ, FEB 2016
Page 5
EVIDENCE TABLES (Continued)
ARE YOU REQUESTING EXPEDITED PROCESSING DUE TO BEING HOMELESS OR IN DANGER OF BECOMING HOMELESS?
To support a request for homeless processing, you must show:
• You are presently homeless or in danger of becoming homeless
• You must have the following service qualifications:
• 90 days of consecutive service; OR
• 90 days of combined service; OR
were discharged prior to 90 days of service due to injury; AND
• Have other than dishonorable military service
• You have a documented disability. You are considered having a documented disability if medical evidence shows:
• Current diagnoses of a disease, disorder, injury, or illness; OR
• Receiving Social Security disability benefits; OR
• Have a disability reasonably certain to continue throughout your lifetime
• Your net worth and income do not exceed certain requirements
Auto Allowance
To support a claim for automobile allowance or adaptive equipment, the evidence must show that you have a service-connected disability
resulting in:
(1) the loss, or permanent loss of use, of at least a foot or a hand; OR
(2) permanent impairment of vision of both eyes, resulting in:
(a) vision of 20/200 or less in the better eye with corrective glasses; OR
(b) vision of 20/200 or better, if there is a severe defect in your peripheral vision; OR
(3) deep partial thickness or full thickness burns resulting in scar formation that cause contractures and limit motion of one or more extremities
of the trunk and preclude effective operation of an automobile; OR
(4) amyotrophic lateral sclerosis (ALS).
NOTE - You may be entitled to only adaptive equipment if you have ankylosis ("freezing") of at least one knee or one hip due to service-connected
disability. Medical evidence, including a VA examination, will show these things. VA will provide an examination if it determines that one is
necessary.
Specially Adapted Housing or Special Home Adaptation (Continued)
To support that you have a qualifying condition for SHA the evidence must show:
• Blindness with central visual acuity of 20/200 or worse in each eye using a standard correcting lens; OR
• Blindness such that the visual field in each eye subtends an angle no greater than 20 degrees; OR
• Permanent and total disability from loss, or loss of use, of both hands; OR
• Permanent and total disability from a severe burn injury meaning
• deep partial thickness burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one
extremity and the trunk; OR
• full thickness or subdermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk; OR
• residuals of inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease).
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.
IMPORTANT: For additional benefits to be payable for a child, the veteran must be entitled to compensation and evaluated as 30 percent or more
disabling.
HOW VA DETERMINES THE EFFECTIVE DATE.
If we grant your claim, the beginning date of your entitlement or increased entitlement to benefits will generally be based on the following factors:
• When we received your claim, OR
• When the evidence shows a level of disability that supports a certain rating under the rating schedule
If VA received your claim prior to or within one year of your separation from the military, entitlement will be from the day following the date of your separation.
HOW VA DETERMINES THE DISABILITY RATING.
When we find disabilities to be service-connected, we assign a disability rating. That rating can be changed if there are changes in your condition. Depending on the disability involved, we will
assign a rating from 0 percent to as much as 100 percent. VA uses a schedule for evaluating disabilities that is published as title 38, Code of Federal Regulations, Part 4. In rare cases, we can
assign a disability level other than the levels found in the schedule for a specific condition if your impairment is not adequately covered by the schedule.
We consider evidence of the following in determining disability rating:
• Nature and symptoms of the condition;
• Severity and duration of the symptoms; AND
• Impact of the condition and symptoms on employment.
Examples of evidence that you should tell us about or give to us that may affect how we assign a disability evaluation include the following:
• Information about on-going treatment records, including VA or other Federal treatment records, you have not previously told us about;
• Social Security determinations;
• Statements from employers as to job performance, lost time, or other information regarding how your condition(s) affect your ability to work; OR
• Statements discussing your disability symptoms from people who have witnessed how the the symptoms affect you.
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 Federal relay number is 711. VA forms are available at www.va.gov/vaforms.
VA FORM 21-526EZ, FEB 2016
Page 6
EVIDENCE TABLES (Continued)
If you wish to make a claim for veterans non service-connected pension benefits because you have little or no income, use VA Form 21-527EZ, Application for Pension. VA forms are
available at www.va.gov/vaforms. If you cannot access this form, write the word "Pension" in Item 13, or at the top of the attached application and VA will send you the form.
IMPORTANT
Page 7
OMB Control No. 2900-0747
Respondent Burden: 25 minutes
Expiration Date: 11/30/2017
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 10 before completing the form.
SECTION I: IDENTIFICATION AND CLAIM INFORMATION
1. VETERAN/SERVICE MEMBER NAME (First, Middle Initial, Last)
2. VETERAN'S SOCIAL SECURITY NUMBER
5. DATE OF BIRTH (MM,DD,YYYY)
6. SEX
3. HAVE YOU EVER FILED A CLAIM WITH VA?
YES NO
YES NO
(If "Yes," provide your file
number in Item 4)
4. VA FILE NUMBER
9A. SERVICE
(Check all that apply)
ARMY NAVY MARINE CORPS AIR FORCE COAST GUARD
9B. COMPONENT
(Check all that apply)
ACTIVE RESERVES NATIONAL GUARD
12A. PREFERRED E-MAIL ADDRESS
(If applicable)
12B. ALTERNATE E-MAIL ADDRESS (If applicable)
8B. POINT OF CONTACT (Name of
person that VA can contact in order
to get in touch with you)
8A. ARE YOU CURRENTLY HOMELESS OR AT RISK
OF BECOMING HOMELESS?
APPLICATION FOR DISABILITY COMPENSATION
AND RELATED COMPENSATION BENEFITS
(If "Yes," complete Items 8B & 8C)
8C. POINT OF CONTACT TELEPHONE NUMBER
(Include Area Code)
10A. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
10B. FORWARDING ADDRESS AND EFFECTIVE DATE (Provide the date you will be living at this address)
11. PREFERRED TELEPHONE NUMBER
VA FORM
FEB 2016
SUPERSEDES VA FORM 21-526EZ, MAY 2015,
WHICH WILL NOT BE USED.
21-526EZ
YearDayMonth
FEMALEMALE
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
7. VETERAN'S SERVICE NUMBER (If applicable)
Year
Day
Month
EFFECTIVE DATE:
DISABILITIES
A. NAME AND LOCATION
13. LIST THE DISABILITY(IES) YOU ARE CLAIMING
(If applicable, identify whether a disability is due to a service-connected disability, is due to confinement as a
Prisoner of War, is due to exposure to Agent Orange, Asbestos, Mustard Gas, Ionizing Radiation, or Gulf War Environmental Hazards, or is related to benefits
under 38 U.S.C. 1151).
Please list your contentions below. See the following examples, for more information:
• Example 1: Hearing loss
• Example 2: Diabetes-Agent Orange (exposed 12/72, Da Nang)
• Example 3: Left knee - secondary to right knee
B. DATE(S) OF TREATMENT
2.
4.
6.
8.
10.
12.
14.
16.
18.
19.
20.
17.
15.
13.
11.
9.
7.
5.
3.
14. LIST VA MEDICAL CENTER(S) (VAMC) AND DEPARTMENT OF DEFENSE (DOD) MILITARY TREATMENT FACILITIES (MTF) WHERE YOU RECEIVED TREATMENT
AFTER DISCHARGE FOR YOUR CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES:
Page 8
1.
VA FORM 21-526EZ, FEB 2016
VETERANS SOCIAL SECURITY NO.
SECTION III: SERVICE PAY
SECTION II: SERVICE INFORMATION
VA Form 21-2680 or, if based on nursing home attendance, VA Form 21-0779
20A. DID/DO YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE/RETIRED PAY?
IMPORTANT: Submission of this application constitutes an election of VA compensation in lieu of military retired pay if it is determined you are entitled to both
benefits. If you are entitled to receive military retired pay, your retired pay may be reduced by the amount of any VA compensation that you are awarded. VA will
notify the Military Retired Pay Center of all benefit changes. Receipt of military retired pay or Voluntary Separation Incentive (VSI) and VA compensation at the same
time may result in an overpayment, which may be subject to collection. However, if you do not want to receive VA compensation in lieu of military retired pay, you
should check the box in Item 21. Please note that if you check the box in Item 21, you will not receive VA compensation, if granted.
20C. LIST TYPE (If known)
VA FORM 21-526EZ, FEB 2016
21. I want military retired pay instead of VA compensation
(If "Yes," complete Items 20B and 20C)
20B. LIST AMOUNT (If known)
Page 9
$
18B. DATE OF ACTIVATION:
(MM,DD,YYYY)
18A. ARE YOU CURRENTLY ACTIVATED ON FEDERAL
ORDERS WITHIN THE NATIONAL GUARD OR
RESERVES?
17D. CURRENT OR LAST ASSIGNED NAME AND ADDRESS OF UNIT:
17E. CURRENT OR ASSIGNED PHONE
NUMBER OF UNIT
(Include Area
Code)
YES NO
15B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER: 15A. DID YOU SERVE UNDER ANOTHER NAME?
16B. RELEASE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE SERVICE
(MM,DD,YYYY)
16D. PLACE OF LAST OR ANTICIPATED SEPARATION16C. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?
(If "No," skip to Item 16A)(If "Yes," complete Item 15B)
16A. MOST RECENT ACTIVE SERVICE ENTRY DATE
(MM,DD,YYYY)
17A. ARE YOU CURRENTLY SERVING OR HAVE YOU EVER SERVED IN
THE RESERVES OR NATIONAL GUARD?
(If "Yes," complete Items 17B thru 17F)
17C. OBLIGATION TERM OF SERVICE
YES NO
YES NO
YES NO
NOTE: IF YOU WISH TO CLAIM ANY OF THE FOLLOWING, COMPLETE AND ATTACH THE REQUIRED FORM(S) AS STATED BELOW
(VA forms are available at www.va.gov/vaforms).
VA Form 21-686c and, if claiming a child aged 18-23 years and in school, VA Form 21-674
Individual Unemployability
Auto Allowance
Veteran/Spouse Aid and Attendance benefits
VA Form 21-8940 and 21-4192
VA Form 26-4555
VA Form 21-4502
Dependents
For:
Required Form(s):
17B. COMPONENT
17F. ARE YOU CURRENTLY
RECEIVING INACTIVE DUTY
TRAINING PAY?
RESERVES
NATIONAL
GUARD
From:
To:
YES NO
18C. ANTICIPATED SEPARATION DATE:
(MM,DD,YYYY)
(If "Yes," complete Items 18B & 18C)
19A. HAVE YOU EVER BEEN A PRISONER OF WAR? 19B. DATES OF CONFINEMENT (MM,DD,YYYY)
YES NO
(If "Yes," complete Item 19B)
From:
To:
(If "No," skip to Item 18A)
22. I elect to waive VA benefits for the days I accrued inactive duty training pay in order to retain my inactive duty training pay.
IMPORTANT: You may elect to keep the training pay for inactive duty training days you received from the military service department. However, to be legally
entitled to keep your training pay, you must waive VA benefits for the number of days equal to the number of days for which you received training pay. In most
instances, it will be to your advantage to waive your VA benefits and keep your training pay.
If you waive VA benefits to receive training pay by checking the box in Item 22, VA will adjust your VA award to withhold future benefits equal to the total number of
inactive duty for training days waived and at the monthly rate in effect for the fiscal year period for which you received training pay. Your normal VA rate will be
restored when the sufficient numbers of days' benefits have been withheld.
Specially Adapted Housing or Special Home Adaptation
Post-Traumatic Stress Disorder VA Form 21-0781 and 21-0781a
NOYES
( )
Month
Day
Year
Year
Day
Month
Month Day
Year
Month Month
Day
Day
Year
Year
VETERANS SOCIAL SECURITY NO.
Month
Day
Year
Month
Day
Year
26. 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 box below ONLY if you DO NOT want your claim considered for
rapid processing under the FDC Program because you plan on submitting further evidence in support of your claim.
23. 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 23, 24 and 25 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.
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.
PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation 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.
VA FORM 21-526EZ, FEB 2016
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. 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.
Page 10
27A. VETERAN/SERVICE MEMBER/ALTERNATE SIGNER SIGNATURE (REQUIRED)
SECTION VI: WITNESSES TO SIGNATURE
29B. PRINTED NAME AND ADDRESS OF WITNESS
28A. SIGNATURE OF WITNESS
(If veteran signed above using an "X")
29A. SIGNATURE OF WITNESS (If veteran signed above using an "X")
27B. DATE SIGNED
28B. PRINTED NAME AND ADDRESS OF WITNESS
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.
I certify I have received the notice attached to this application titled, Notice to Veteran/Service Member of Evidence Necessary to Substantiate a Claim for Veterans
Disability Compensation and Related Compensation 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 26, 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.
ALTERNATE SIGNER: By signing on behalf of the claimant, I certify that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act
on behalf of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a spouse or other
relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND, that the claimant is under the age
of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to certify that the statements made on the form are
true and complete; OR, is physically unable to sign this form.
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that VA may request
further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant if necessary. Examples of evidence
which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN); a certificate or order from a court with competent jurisdiction
showing your authority to act for the claimant with a judge's signature and date/time stamp; copy of documentation showing appointment of fiduciary; durable power of
attorney showing the name and signature of the claimant and your authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement
from an institution or person responsible for the care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such
authorization.
SECTION V: CLAIM CERTIFICATION AND SIGNATURE
SECTION VII: POWER OF ATTORNEY (POA) SIGNATURE
I certify that the claimant has authorized the undersigned representative to file this supplemental claim on behalf of the claimant and that the claimant is aware and
accepts the information provided in this document. I certify that the claimant has authorized the undersigned representative to state that the claimant certifies the truth
and completion of the information contained in this document to the best of claimant's knowledge.
NOTE: A POA's signature will not be accepted unless at the time of submission of this claim a valid VA Form 21-22, Appointment of Veterans Service Organization as
Claimant's Representative, or VA Form 21-22a, Appointment of Individual As Claimant's Representative, indicating the appropriate POA is of record with VA.
30A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE 30B. DATE SIGNED
Account No.:
25. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the
bottom left of your check)
24. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank
where you want your direct deposit)
Account No.:
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL
INSTITUTION OR CERTIFIED PAYMENT AGENT
SAVINGSCHECKING
SECTION IV: DIRECT DEPOSIT INFORMATION
VETERANS SOCIAL SECURITY NO.
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NOTICE TO VETERANSERVICE MEMBER OF EVIDENCE NECESSARY TO (City of North Reading)

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Completed 14 July 2020

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