Va Form 21-4138 - Statement In Support Of Claim

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OMB Approved No. 2900-0075

Respondent Burden: 15 minutes

STATEMENT IN SUPPORT OF CLAIM

PRIVACY ACT INFORMATION: The law authorizes us to request the information we are asking you to provide on this form (38 U.S.C. 501(a) and (b)). The

responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed outside the Department of Veterans Affairs (VA) only if the disclosure is

authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22, Compensation, Pension, Education and Rehabilitation

Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the law.

Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB

Control Number. Public reporting burden for this collection of information is estimated to average 15 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. If you have

comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your

comments.

(Type or print)

VA FILE NO.

FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

SOCIAL SECURITY NO.

C/CSS -

The following statement is made in connection with a claim for benefits in the case of the above-named veteran:

INFORMAL CLAIM FOR PENSION WITH A&A

VETERANS DATE OF BIRTH:

DATE ENTERED SERVICE:

DATE OF DISCHARGE:

MILITARY SERIAL NUMBER:

BRANCH OF SERVICE:

IF CLAIM IS FOR A WIDOW COMPLETE THIS SECTION

VETERANS DATE OF DEATH:

NAME OF SURVIVING SPOUSE:

(CONTINUE ON REVERSE)

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

SIGNATURE

DATE SIGNED

ADDRESS

TELEPHONE NUMBERS (Include Area Code)

DAYTIME

EVENING

1000 Sunset Blvd, Ste 115

Rocklin, CA 95765

(916) 780-3290

PENALITY: The law provides severe penalties which include fine or inprisonment, or both, for the willful submission of any statement or evidence of a material fact,

knowing it to be false.

VA FORM

21-4138

EXISTING STOCKS OF VA FORM 21-4138,

JUN 2000

APR 1994, WILL BE USED