- VA Claims

Section 1 of 19

Today's Date

Date: *

Section 2 of 19

Contact Information

First: *

Middle:

Last: *

Ph 1: *

Ph 2: *

Ph 3: *

Email: * Example: John@example.com

SSN 1: *

SSN 2: *

SSN 3: *

Date of Birth: *

Previous VA Claim

Have you ever filed a claim with VA? *

Yes No

Section 3 of 19

Mailing Address

Number and Street: * Example: 2703 Cardigan Court

Apt or Unit Number: Examples: A, #03, etc.

City: * Example: San Antonio

State or Territory: *

Country:

Zip / Postal Code: * Example: 30815

VA Employee: * Is Veteran a VA Employee? Includes VA work study and VA internship.

Yes No

Medications

List current medications prescribed for any condition you are claiming. These will be included in your claim to support service connection.

Medication One:

Medication Two:

Medication Three:

Medication Four:

Medication Five:

Section 4 of 19

Toxic Exposure Information

Refer to: PACT ACT and Public Health Military Exposures

Is the veteran claiming any toxic exposure disabilities? *

Yes No

Section 5 of 19

Gulf War Hazard Locations

Did the veteran serve in any Gulf War hazard locations?

Iraq, Kuwait, Saudi Arabia, The neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, The United Arab Emirates, Oman, Yemen, Lebanon, Somalia, Afghanistan, Israel, Egypt, Turkey, Syria, Jordan, Djibouti, Uzbekistan, The Gulf of Aden, The Gulf of Oman, The Persian Gulf, The Arabian Sea, The Red Sea

Yes No

Section 6 of 19

Gulf War Hazard Location Dates

From: Date first arrived (MM/YYYY)

To: Date departed (MM/YYYY)

Section 7 of 19

Herbicide (e.g., Agent Orange) Locations

Did the veteran serve in any of the following Herbicide locations?

The Republic of Vietnam (including the 12 nautical mile territorial waters), Thailand at any United States or Royal Thai base, Laos, Cambodia at Mimot or Krek, Kampong Cham Province, Guam or American Samoa (or in their territorial waters), Johnston Atoll (or a ship that called at Johnston Atoll), Korean demilitarized zone, Aboard a C-123 aircraft known to have been used to spray an herbicide agent

Yes No

Section 8 of 19

Herbicide (e.g., Agent Orange) Location Dates

From: Date first arrived (MM/YYYY)

To: Date departed (MM/YYYY)

Section 9 of 19

More Exposures

Has veteran been exposed to any more toxins?

More Toxic Exposures:

Yes No

Section 10 of 19

Toxic Exposures List

Choose 'Yes' or 'No' for any of the following toxins the veteran is claiming exposure to.

From: Date veteran was first exposed to any of the toxins listed above

To: Date veteran was last exposed to any of the toxins listed above

If veteran was exposed to Other Toxins or exposed multiple times, please provide all additional dates and locations of potential exposure: Example: "04/2001, Japan, Radiation"

Section 11 of 19

Disabilities the Veteran is Claiming

List each disability the veteran wants to claim. Check if any conditions can be claimed secondary to rated disabilities. Secondary claims are often easier to get approved.

💡 Helpful Tips

If the veteran has Tinnitus, they can claim Anxiety secondary to Tinnitus
If they have any service connected foot disability, they can claim Plantar Fasciitis secondary to foot condition
Sleep Apnea secondary to PTSD
Erectile dysfunction secondary to PTSD or anxiety (If the veteran already has a rating for either PTSD or Anxiety)

Section 12 of 19

Disability One

Name of Disability One: Example: HEARING LOSS, DIABETES, LEFT KNEE SECONDARY TO RIGHT KNEE

Exposure, Event, or Injury One: Example: NOISE, AGENT ORANGE, ENEMY MORTAR FIRE

Cause or Relation to Service One: Example: HEAVY EQUIPMENT OPERATOR IN SERVICE, SERVICE IN GULF WAR

Approximate Date Disability Began or Worsened:

Section 27 of 19

Disabilities Treated at VA and DoD Medical Centers

If treatment began after 2012 at a VA facility, the VA obtains records automatically and dates are not required.

Disability, Name of Medical Center, and Location One: Example: Diabetes, Walter Reed National Military Medical Center, Bethesda, MD. Read this if still confused

Date of Treatment One: Examples: 07-1974, 03-1985

Disability, Name of Medical Center, and Location Two:

Date of Treatment Two:

Disability, Name of Medical Center, and Location Three:

Date of Treatment Three:

Section 28 of 19

Military Service

Branch: *

Most Recent Active Service Entry Date:

Most Recent Active Service Exit Date:

Place of Last or Anticipated Separation:

Did you Deploy to Combat Zone after 9-11-2001:

Yes No

Section 29 of 19

Additional Periods of Service

Additional Service Entry Date:

Additional Service Exit Date:

Did you serve in the Reserves or National Guard?

Reserves or National Guard:

Component:

Obligation From:

Obligation To:

Current or Last Assigned Name and Address of Unit:

Unit Name and Address:

Unit Phone Number: Format: 555-555-5555 (10 digits)

Currently Activated?

Yes No

Date of Activation:

Date of Separation:

Section 32 of 19

Military Retired Pay

Receiving Military Retired Pay?

Yes No

Monthly Amount:

Retired Status:

Branch Retired From:

Have You Received a Lump Sum Payment From Your Branch of Service?

Lump Sum Payment From Your Branch of Service?

Did you receive a lump sum payment? *

Yes No Recommended

⚠ Warning: VA will withhold compensation equal to any lump sum payment you received.

Section 35 of 19

Direct Deposit

The VA requires direct deposit information on VA Form 21-526EZ for benefit payments. This information will be included in your claim document. Your banking information is encrypted and used only to complete your VA claim form.

Account Number: *

Account Type: *

Bank Name: *

Routing Number: *

Section 36 of 19

Statement in Support of Claim

Supporter's Name: A "Buddy Statement" from someone who witnessed your service or disability can significantly strengthen your claim. This is optional but recommended.

Supporter's Relationship:

Where should we send your completed claim?

Enter the email address where you want your finished, merged VA claim form delivered.

Delivery Email Address: * Example: John@example.com

Today's Date

Contact Information

Previous VA Claim

Mailing Address

Medications

Toxic Exposure Information

Gulf War Hazard Locations

Gulf War Hazard Location Dates

Herbicide (e.g., Agent Orange) Locations

Herbicide (e.g., Agent Orange) Location Dates

More Exposures

Toxic Exposures List

Disabilities the Veteran is Claiming

💡 Helpful Tips

Disability One

Disabilities Treated at VA and DoD Medical Centers

Military Service

Additional Periods of Service

Did you serve in the Reserves or National Guard?

Current or Last Assigned Name and Address of Unit:

Military Retired Pay

Have You Received a Lump Sum Payment From Your Branch of Service?

Direct Deposit

Statement in Support of Claim

Where should we send your completed claim?

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