Fillable NOTICE TO VETERAN/SERVICE MEMBER OF EVIDENCE NECESSARY TO (County of Fulton)

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NOTICE TO VETERAN/SERVICE MEMBER OF EVIDENCE NECESSARY TO (County of Fulton)

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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 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 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 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.
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
JAN 2014
21-526EZ
Page 1
SUPERSEDES VA FORM 21-526EZ, AUG 2013,
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.
IMPORTANT: If you are filing your claim prior to or within one year of your separation from the military, please provide a certified
copy of your DD Form 214, "Certificate of Release or Discharge from Active Duty" as early as possible following your separation, as
this may expedite the completion of 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.
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, JAN 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
.
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, JAN 2014
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
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
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.
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.
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)
VA FORM 21-526EZ, JAN 2014
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).
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.
EVIDENCE TABLES (Continued)
Page 5
VA FORM 21-526EZ, JAN 2014
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
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.
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 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.
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.
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 1-800-829-4833. VA forms are available at www.va.gov/vaforms
.
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" under Item 9 or at
the top of the attached application and VA will send you the form.
IMPORTANT
Page 6
VA FORM 21-526EZ, JAN 2014
DISABILITIES
5.
20.
25.
21.
22.
23.
24.
26.
27.
28.
29.
30.
19.
18.
17.
16.
14.
13.
12.
11.
15.
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 8 before completing the form.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
B. DATE(S) OF TREATMENT
9. 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
11B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER
7B. FORWARDING ADDRESS
Street address, rural route, or P.O. Box Apt. number
City State ZIP Code Country
DAYTIME
SECTION II: SERVICE INFORMATION
11A. DID YOU SERVE UNDER ANOTHER NAME?
12C. RELEASE DATE OR ANTICIPATED DATE
OF RELEASE FROM ACTIVE SERVICE
8B. ALTERNATE E-MAIL ADDRESS (If applicable)
7C. TELEPHONE NUMBERS (Include Area Code)
(If "Yes," provide your file number in Item 6)
7A. CURRENT MAILING ADDRESS
12B. BRANCH OF SERVICE
5. HAVE YOU EVER FILED A CLAIM WITH VA?
12E. PLACE OF LAST OR ANTICIPATED SEPARATION
10. LIST VA MEDICAL CENTER(S) WHERE YOU RECEIVED TREATMENT FOR YOUR CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES:
NOTE: IF YOU WISH TO CLAIM ANY OF THE FOLLOWING DISABILITY COMPENSATION RELATED BENEFITS, COMPLETE AND ATTACH TO THIS
FORM THE REQUIRED BENEFIT FORM(S) AS STATED (VA forms are available at www.va.gov/vaforms).
APPLICATION FOR DISABILITY COMPENSATION
AND RELATED COMPENSATION BENEFITS
A. NAME AND LOCATION OF VA MEDICAL CENTER
SECTION I: IDENTIFICATION AND CLAIM INFORMATION
VA Form 21-686c and, if claiming a child aged 18-23 years and in school, VA Form 21-674
VA Form 21-2680 or, if based on nursing home attendance, VA Form 21-0779
12D. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?
4. SEX
MALE
FEMALE YES NO
3. DATE OF BIRTH (MM,DD,YYYY) 2. SOCIAL SECURITY NUMBER
OMB Control No. 2900-0747
Respondent Burden: 25 minutes
City State ZIP Code Country
Street address, rural route, or P.O. Box Apt. number
CELL PHONE
( )
EVENING
( )
( )
8A. PREFERRED E-MAIL ADDRESS (If applicable)
6. VA FILE NUMBER
(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)?
(If "Yes," provide date of activation in Item 13B)
13B. DATE OF ACTIVATION (MM,DD,YYYY)
1. VETERAN/SERVICE MEMBER NAME (Last, first, middle)
SUPERSEDES VA FORM 21-526EZ, AUG 2013,
WHICH WILL NOT BE USED.
Page 7
VA FORM
JAN 2014
21-526EZ
Individual Unemployability
Specially Adapted Housing or Special Home Adaptation
Auto Allowance
Veteran/Spouse Aid and Attendance benefits
VA Form 21-8940 and 21-4192
VA Form 26-4555
VA Form 21-4502
Dependents
Benefits for: Required Form(s):
1.
2.
3.
4.
6.
7.
8.
9.
10.
NO
YES NO
YES NO
YES
22A. VETERAN/SERVICE MEMBER SIGNATURE (REQUIRED)
16A. DID/DO YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE/RETIRED PAY?
SECTION VI: WITNESSES TO SIGNATURE
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 17. Please note that if you check the box in Item 17, you will not receive VA compensation, if granted.
SECTION IV: DIRECT DEPOSIT INFORMATION
SECTION III: SERVICE PAY
16C. LIST TYPE (If known)
Account No.: Account No.:
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 21, 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.
24B. PRINTED NAME AND ADDRESS OF WITNESS
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.
SECTION V: CLAIM CERTIFICATION AND SIGNATURE
23A. SIGNATURE OF WITNESS (If veteran signed above using an "X")
24A. SIGNATURE OF WITNESS (If veteran signed above using an "X")
22B. DATE SIGNED
23B. PRINTED NAME AND ADDRESS OF WITNESS
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.
17.
18. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA)
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A
FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT
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 18, 19 and 20 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.
20. ROUTING OR TRANSIT NUMBER (The first nine numbers located
at the bottom left of your check)
19. NAME OF FINANCIAL INSTITUTION (Please provide the name of the
bank where you want your direct deposit)
I want military retired pay instead of VA compensation.
(If "Yes," complete Items 16B and 16C)
16B. LIST AMOUNT (If known)
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.
$
21. 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.
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.
15B. DATES OF CONFINEMENT15A. HAVE YOU EVER BEEN A PRISONER OF WAR?
(If "No," skip to Item 16A)(If "Yes," complete Item 15B)
14A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?
14B. WHAT IS THE TELEPHONE NUMBER OF
YOUR CURRENT UNIT? (Include Area Code)
( )
To:From:
Page 8
VA FORM 21-526EZ, JAN 2014
SAVINGS
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YES NO
YES
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NOTICE TO VETERANSERVICE MEMBER OF EVIDENCE NECESSARY TO (County of Fulton)

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Completed 13 February 2021

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