DOCUMENTATION REQUIRED - READ CAREFULLY
Please submit photocopies of documents because they will not be returned unless a certified copy is specified.
A. Documentation of Service and Separation under Honorable
For spouses and mothers of disabled veterans, who checked item 10 or
Conditions
12, submit the following:
Submit any of the documents listed below as documentation,
An official statement, dated 1991 or later, from the Department of
provided they are dated on or after the day of separation from active
Veterans Affairs, or from a branch of the Armed Forces, certifying:
duty military service:
1) the present existence of the veterans service-connected disability,
2) the percentage and nature of the service-connected disability or
1. Honorable or general discharge certificate.
disabilities (including the combined percentage),
2. Certificate of transfer to Navy Fleet Reserve, Marine Corps Fleet
3) a notation as to whether or not the service-connected disability is
Reserve, or enlisted Reserve Corps.
rated as permanent and total.
3. Orders of transfer to retired list.
4. Report of separation from a branch of the Armed Forces.
Please Note: When a veteran dies on active duty, the family does not
5. Certificate of service or release from active duty, provided
receive a DD Form 214; the family receives a DD Form 1300, Report of
honorable separation is shown.
Casualty, on which there is no place to record the character of service.
6. Official statement from a branch of the Armed Forces showing
Thus, when a veteran dies on active duty, his or her service should be
that honorable separation took place.
presumed to be under honorable conditions unless the military service
7. Notation by the Department of Veterans Affairs or a branch of the
specifically indicates otherwise.
Armed Forces on an official statement, described in B or C below,
that the veteran was honorably separated from military service.
D. Documentation of Veteran's Death
8. Official statement from the Military personnel records center that
1. If on active military duty at time of death, submit official notice, from a
official service records show that honorable separation took place.
branch of the Armed Forces, of death occurring under honorable
B. Documentation of Service-Connected Disability
conditions.
(Non-Compensable, i.e., Less than 10%); Purple Heart; and
2. If death occurred while not on active military duty, submit certified
Nonservice-Connected Disability Pension.
copy of death certificate.
Submit one of the documents :
E. Documentation of Service or Death During a War, in a Campaign or
1. An official statement, dated 1991 or later, from the Department of
Expedition for which a Campaign Badge is Authorized, or During
Veterans Affairs or from a branch of the Armed Forces, certifying to
the Period Authorized, or During the Period of April 28, 1952
the present existence of the veteran's service-connected disability of
through July 1, 1955.
less than 10%.
Submit documentation of service or death during a war or during the
2. An official citation, document, or discharge certificate, issued by a
period April 28, 1952, through July 1,1955, or during a campaign or
branch of the Armed Forces, showing the award to the veteran of the
expedition for which a campaign badge is authorized.
Purple Heart for wound or injuries received in action.
3. An official statement, dated 1991 or later, from the Department of
F. Documentation of Deceased or Disabled Veteran's Mother's Claim
Veterans Affairs, certifying that the veteran is receiving a nonservice-
for Preference because of Her Husband's Total and Permanent
connected disability pension.
Disability.
C. Documentation of Service-Connected Disability
Submit a statement from husband's physician showing the prognosis
(Compensable, i.e., 10% or More).
of his disease and percentage of his disability.
If you checked Item 9 on the front of this form, submit one of the following
documents:
G. Documentation of Annulment of Remarriage by Widow or Widower
of Veteran.
1. An official statement, dated 1991 or later, from the Department
of Veterans Affairs, or from a branch of the Armed Forces,certifying to
Submit either:
the veteran's present receipt of compensation for service-connected
1. Certification from the Department of Veterans Affairs that entitlement
disability or disability retired pay.
to pension or compensation was restored due to annulment.
2. An official statement, dated 1991 or later, from the Department of
2. A certified copy of the court decree of annulment.
Veterans Affairs, or from a branch of the Armed Forces, certifying that
the veteran has a service-connected disability of 10% or more.
H. Documentation of Veteran's Inability to Work Because of a Service-
3. An official statement or retirement orders from a branch of the Armed
Connected Disability.
Forces, showing that the retired serviceman was retired because of
permanent service-connected disability or was transferred to the
Answer questions 1-7 below:
permanent disability retirement list. The statement or retirement
orders must indicate that the disability is 10% or more.
2. If currently working, what is the veteran's present occupation?
1. Is the veteran currently working? If No, go to Item 3.
Yes
No
4. What was the veteran's military occupation
3. What was the veteran's occupation, if any, before military service?
at the time of separation?
5. Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government?
Yes
No
A. Title and Grade of position most recently, or currently, held B. Name and address of agency
C. Dates of employment
To
:
From:
6. Has the veteran resigned from, been disqualified for, or separated from a position in the Federal civil service or D.C. Government
along the lines of his/her usual occupation because of service-connected disability?
Yes
No
If Yes, submit documentation of the resignation, disqualification, or separation.
7. Is the veteran receiving a civil service retirement pension?
Yes
No
If Yes, give the Civil Service annuity or Federal employee retirement annuity number.
CSA#
Standard Form 15
Page 2 of 2
Revised August 2008
December 2004 edition usable;
all other previous editions are unusable.