Application For Veteran'S Compensation - Illinois Department Of Veterans' Affairs (Page 2 of 2) in pdf

Application For Veteran'S Compensation - Illinois Department Of Veterans' Affairs Page 2

I have/have not applied for and/or received a bonus or similar payments from another State on account of my service.

If “have’ what State? ___________________________________________________

For World War II Veterans only: Compensation show total active service from September 16, 1940 to September 2, 1945.

ACTIVE DOMESTIC SERVICE (EXCLUDING ALASKA)

ACTIVE FOREIGN SERVICE (INCLUDING ALASKA)

Month’s _____________________ Days ________________

Months ___________________

Days__________________

I hereby certify that statements on page 1 are true and correct to the best of my knowledge and belief

__________________________________________________

(Signature of Applicant)

__________________________________________________

(Telephone Number)

Do not write below this line

THIS SECTION FOR DVA USE ONLY

DEPARTMENT OF VETERANS’ AFFAIRS

I hereby certify that the within claim has been examined and is hereby certified for payment of $___________ for service in the

Armed Forces of the United States, as provided by the Illinois Veterans’ Compensation Act.

Examined and Verified by: _________________________________

Dated: ___________________________________

(WW II VETERANS ONLY)

ACTIVE DOMESTIC SERVICE

ACTIVE FOREIGN SERVICE

Months of Service ___________________________________

Months of Service ________________________________

Days of Service _____________________________________

Days of Service __________________________________

Amount Due _______________________________________

Amount Due ____________________________________

TOTAL AMOUNT DUE _____________________________

Examined by: _______________________________________________ Date: _______________________________________

APPLICATION PROCEDURE

1. Complete application

2. Submit a copy (ies) of Veteran’s separation or discharge(s).

3. Mail completed application to the Department of Veterans’ Affairs, P.O. Box

19432, 833 South Spring Street, Springfield, Illinois 62794-9432

Application For Veteran'S Compensation - Illinois Department Of Veterans' Affairs Page 2