Udvma Form 1 - State Of Utah Va Benefits Claims Assistance Disclosure Form printable pdf download

State of Utah VA Benefits Claims Assistance Disclosure Form

The Utah Department of Veterans and Military Affairs provides information and claims preparation

assistance at no charge.

Veterans are welcome to call the department at 801-326-2372.

Veterans submitting claims for VA benefits have rights and protections enumerated in Title 38 Veterans’

Benefits C.F.R (Code of Federal Regulations). These regulations govern individuals providing VA claims

assistance to ensure veterans have responsible, qualified representation in the preparation, presentation, and

prosecution of claims for veterans’ benefits.

Relevant and important provisions of Title 38 include, but are not limited to:

1. Any individual providing VA benefits claims assistance must be accredited by the VA.

2. Federal law restricts charging a veteran, or a member of the veteran’s family, a fee for assisting in the

initial application for VA benefits.

In accordance with Utah Code §71-13-103, the named VA Accredited Claim Representative affirms that:

1. There is no charge to the claimant or a member of the claimant’s family for assistance with the initial

benefits application, and

2. If, as a result of providing assistance for a claim, income is accrued from the sale of a product or other

service to the claimant, the income is both justified and reasonable as compared with income from

similar products and services available in the state.

Name of VA Accredited Claim Representative ____________________________________________

Business address ___________________________________________________________________

Business phone number _____________________________________________________________

VA Accreditation Number ____________________________________________________________

Name of Veteran Claimant ___________________________________________________________

Claimant Address ___________________________________________________________________

Claimant Phone Number _____________________________________________________________

Claim Representative Signature _______________________________________________________

Veteran Claimant/Authorized Representative Signature ____________________________________

Date:_________________________

Pursuant to Utah Code§71-13-103, no provision of this form may be struck out or designated as N/A. A copy of this

completed form shall be provided to the veteran on the day it is signed. Additionally, the Claims Representative must

send a signed copy to the UDVMA within 5 working days (550 Foothill Blvd, Ste 105, Salt Lake City, UT 84113 or

veterans@utah.gov) and retained on file for 3 years.

UDVMA Form 1

May 2015

Udvma Form 1 - State Of Utah Va Benefits Claims Assistance Disclosure Form