Should you apply for the Camp Lejeune Family Member Program?
If the Veteran
Was on active duty and
served at Camp Lejeune for
30 days or more between
August 1, 1953 and
December 31, 1987;
You were the spouse or
dependent of the Veteran
or were in utero of the
Veteran, spouse, or a
dependent during that
You lived or were in utero
on Camp Lejeune for 30
days or more between
August 1, 1953 and
December 31, 1987;
You may meet the criteria for VA's
Camp Lejeune Family Member
NOTE TO APPLICANT: You're applying to the Department of Veterans Affairs (VA). VA will consider the information you
provide on this questionnaire as part of their eligibility determination for this program. Complete the form to the best of your
knowledge and ability in order to establish your eligibility for this program. This program's eligibility criteria will be
determined through the VA. Submission of this application does not guarantee acceptance into this program.
Getting Started: Directions for Applicant, representative or Power of Attorney (POA), please answer all questions.
Applicant Information: Please complete and provide copy of legal documents.
Residency Information: Please answer all questions. If possible, provide copies of documents verifying your residency.
Conditions/Illnesses: Please answer all questions. If you mark the box for Yes, check all the conditions you have been
diagnosed with. A Treating Physician Report form is enclosed for your physician to complete and return with this
application. If you mark the box for No, you may go to the next section.
Health Care Coverage: Please answer all questions and provide your health care coverage, if applicable. (Note: Health
care coverage may also be referred to as health care insurance).
Veteran Information: Please answer all questions, if known.
Certification: Please sign, and date.
For more information go to: www.publichealth.va.gov/exposures/camp-lejeune/index.asp
Customer Service Center: 1-866-372-1144, Fax 512-460-5536
Camp Lejeune Family Member Program
Department of Veterans Affairs, Financial Services Center
PO Box 149200, Austin, TX 78714-9200
The Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of section
3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to
average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be
aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. The purpose of this data collection is
to determine eligibility for benefits.
Privacy Act Information: The authority for collection of the requested information on this form is 38 USC 1787. The
purpose of collecting this information is to determine your eligibility for reimbursement of health care related to conditions
determined to result from contaminated water while you resided at Camp Lejeune, North Carolina, for a period of at least
30 days. The information you provide may be verified by computer matching programs with authoritative sources such as
the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Department of Defense
(DoD), Defense Enrollment Eligibility Reporting System (DEERS), Centers for Medicare & Medicaid Services (CMS) or any
other applicable authoritative source at any time. You are requested to provide your social security number as your VA
record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or
all of the requested information is not provided, given the form's purpose of establishing eligibility for the Camp Lejeune
Family Member Program, it may delay or result in denial of your request for Camp Lejeune Family Member Program
benefits. Failure to furnish the requested information will have no adverse impact on any other VA benefit to which you
may be entitled.
The responses you submit are considered private confidential and may be disclosed outside VA only if the
disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records number
23VA16. For example, information including your social security number may be disclosed to the Department of Defense,
contractors, trading partners, health care providers and other suppliers of health care services to determine your eligibility
for medical benefits and payment for services.
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