SECTION IV - AUTHORIZATION, CERTIFICATION, AND SIGNATURE
26. REMARKS (If any)
AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the 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 except protected health information, and I waive any privilege which makes the
CERTIFICATION OF STATEMENTS: I CERTIFY THAT as a result of my service-connected disabilities, I am unable to secure or follow any substantially gainful
occupation and that the statements in this application are true and complete to the best of my knowledge and belief. I understand that these statements will be considered in
determining my eligibility for VA benefits based on unemployability because of service-connected disability.
I UNDERSTAND THAT IF I AM GRANTED SERVICE-CONNECTED TOTAL DISABILITY BENEFITS BASED ON MY UNEMPLOYABILITY, I MUST IMMEDIATELY INFORM
VA IF I RETURN TO WORK. I ALSO UNDERSTAND THAT TOTAL DISABILITY BENEFITS PAID TO ME AFTER I BEGIN WORK MAY BE CONSIDERED AN
OVERPAYMENT REQUIRING REPAYMENT TO VA.
27. SIGNATURE OF CLAIMANT (Do Not Print) (Sign in ink)
WITNESS TO SIGNATURE OF CLAIMANT IF MADE "X" MARK. NOTE: Signature made by mark must be witnessed by two persons to whom the person making the
statement is personally know and the signature and address of such witnesses must be shown below.
29A. SIGNATURE OF WITNESS (Sign in ink)
29B. ADDRESS OF WITNESS
30A. SIGNATURE OF WITNESS (Sign in ink)
30B. ADDRESS OF WITNESS
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.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Regulations 1.576 for routine uses (i.e., 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) as 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. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under
Title 38, U.S.C. 5101(c)(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior
to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits provided under the law. The responses you submit are
considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
VA FORM 21-8940, OCT 2017
28. DATE SIGNED
VETERAN'S SOCIAL SECURITY NO.
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 45 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.
SECTION V - WHERE TO SEND CORRESPONDENCE
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
844-531-7818 (Toll Free) OR