Application For Veteran'S Compensation - Illinois Department Of Veterans' Affairs

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(CHECK ONE BOX)
DVA FILE #
WORLD WAR II
DESERT STORM
_____________________
KOREAN
GLOBAL WAR ON TERRORISM
VIETNAM
STATE OF ILLINOIS
DEPARTMENT OF VETERANS’ AFFAIRS
APPLICATION FOR VETERAN’S COMPENSATION
By Living Veteran
I, ___________________________________________________________________________________________________________
(Last Name)
(First)
(Middle)
(SSN)
(Branch of Service)
(Serial Number)
The name under which I entered the service (if different from above) was__________________________________________________
Present mailing address ________________________________________________________________________________________
(Number)
(Street)
(City or Town)
(County)
(State)
(Zip Code)
do hereby make application for the Illinois Veterans’ Compensation for my service from
_______________________________________, ________ to _____________________________________________, ___________
(Month)
(Day)
(Year)
(Month)
(Day)
(Year)
as evidence by my enclosed copy of Report of Separation (DD Form 214)
I was awarded the
Korean Service Medal
Vietnam Service Medal
Armed Force Expeditionary Medal-Vietnam
Southwest Asia Service Medal
Global War on Terrorism Expeditionary Medal
Global War on Terrorism Service Medal
Afghanistan Campaign Medal
Iraq Campaign Medal
Global War on Terror only: must have served at least 30 consecutive or 60 nonconsecutive days foreign or sea service.
I entered active service from _____________________________________________________ on: ____________________________
(City)
(State)
(Date)
I was separated from active service at _____________________________________________________________________________
(Post, Camp or Station)
My place and date of birth was __________________________________________________________________________________
(City)
(County)
(State)
(Month)
(Day)
(Year)
My type of separation from active service was honorable ______ under honorable conditions______
I was a resident of Illinois for __________ years and __________ months immediately prior to entry into the Armed Forces of the
United States
At time of entry into active service I was residing at _________________________________________________________________
(Number)
(Street)
___________________________________________________________________________________________________________
(City or Town)
(County)
(State)
My address at time of separation from service (Permanent address) was__________________________________________________
(Number)
(Street)
____________________________________________________________________________________________________________
(City or Town)
(County)
(State)
-IMPORTANT NOTICE-
This state agency is requesting disclosure of information necessary to accomplish the statutory purpose of Ch. 122, 30-14.2. Disclosure
IL 497-0473
is REQUIRED: failure to provide this information will prevent the claim from being processed. This form has been approved by the
Revised 06/2010
Forms Management Center.

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