SECTION X: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE
(NOTE: REQUIRED ONLY IF ITEM 33A IS BLANK)
SECTION XI: POWER OF ATTORNEY (POA) SIGNATURE
(NOTE: POA'S CANNOT SIGN FOR AN ORIGINAL CLAIM ONLY)
SECTION IX: WITNESSES TO SIGNATURE
SECTION VIII: CLAIM CERTIFICATION AND SIGNATURE
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. For the limited purpose of providing VA with this information as it may relate to my claim, I waive any privilege that may
apply and would otherwise make the information confidential and not disclosable.
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, APR 2020
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.
35B. PRINTED NAME AND ADDRESS OF WITNESS
34A. SIGNATURE OF WITNESS
(Sign in ink) (Note: Only sign if veteran signed in Item 33A using
an "X")
35A. SIGNATURE OF WITNESS (Sign in ink) (Note: Only sign if veteran signed in Item 33A using
an "X")
34B. PRINTED NAME AND ADDRESS OF WITNESS
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 1, on page
8, indicating I want my claim processed under the standard claim process because I plan to submit additional evidence in support of my claim.
I certify that the claimant has authorized the undersigned representative to file this 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.
37A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE (Sign in ink)
VETERANS SOCIAL SECURITY NO.
Page 12
33B. DATE SIGNED (MM-DD-YYYY)
VETERAN/SERVICEMEMBER CERTIFICATION AND SIGNATURE
33A. VETERAN/SERVICE MEMBER SIGNATURE (REQUIRED) (Sign in ink)
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it
to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
36A. ALTERNATE SIGNER SIGNATURE (REQUIRED) (Sign in ink)
I certify that by signing on behalf of the claimant, 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 a 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.
36B. DATE SIGNED (MM-DD-YYYY)
37B. DATE SIGNED (MM-DD-YYYY)