Veterans' Preference Eligibility Form Page 2
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411. Preference for a Spouse of a living veteran based on the
(a) Are you presently married to the
Yes No
fact that the veteran, because of a service-connected
veteran?
disability, has been unable to qualify for a Federal or D.C.
Government job or any other position along the lines of the
(If No, you are not eligible for
B and H
veteran’s usual occupation.
preference and should not submit
this form.)
12. Preference for a Widow or Widower of a Veteran.
(a) Were you married to the veteran
Yes No
when he or she died? (If No, you
are not eligible for preference and
should not submit this form.)
A, C, D, and F
(b) Have you remarried since the
(Submit F when
veteran’s death? Do not count
applicable.)
marriages that were annulled.
(If Yes, you are not eligible for
preference and should not submit
this form.)
13. Preference for Mother of a veteran who has a service-
Yes
No
connected disability that is permanent and totally disabling,
(a) Are you married now?
Disabled Veteran
or who is deceased, provided you are or were married to
B, E, and H
the father of the veteran, and
(Submit E when
(b) Are you separated?
--- your husband (either the veteran’s father or your
applicable.)
husband as a result of remarriage) is totally and
(If Yes, do not complete (c), go to
permanently disabled, or
(d).)
--- you are now widowed, divorced or separated from the
(c) If married now, is your husband
veteran’s father and have not remarried, or
totally and permanently disabled?
--- you are widowed or divorced from the veteran’s father
(d) If the veteran is deceased, did
and have remarried, but you are now widowed,
he/she die on active duty?
Deceased Veteran
divorced or separated from the husband of your
A, C, D, and E
remarriage.
(If your answer is No to item 13(c) or
(Submit E when
13(d), you are not eligible for
applicable.)
preference and should not submit this
form.)
I certify that all of the statements made in this application are true, complete and correct to the best of my
Subject to 28 U.S.C.
§101(21)
knowledge and belief and are made in good faith. (A false answer to any question may be grounds for not employing you or for dismissing
you after you begin work, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001)).
This form must be signed by all persons claiming a veterans’ preference
Signature of person claiming preference
Date signed
(Month, Day, Year)
FOR USE BY HUMAN RESOURCES
Name and Title of person who verified veterans’
Date of verification
ONLY
preference
(Month, Day, Year)
Preference entitlement was verified
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