Form 102 - Authorization For Disability Record (Disabled Veteran) - Westchester County Department Of Human Resource
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1Westchester County
AUTHORIZATION FOR DISABILITY RECORD
Department of Human Resources
Form 102(1/14)
148 Martine Avenue, Suite 100
White Plains, New York 10601
1
TO BE COMPLETED BY DISABLED VETERAN:
To Manager, Department Of Veterans Affairs
, N.Y.
I hereby authorize you to furnish the Westchester County Department of Human Resources with
the data requested in Section 2, below, pertaining to my disability status. You are released from
all liability in complying with this request. It is understood that all information furnished with be
treated as confidential.
Date:
Veteran's Signature:______________________
PRINT FULL NAME
VA CLAIM NO.
SERIAL NO.
ADDRESS
NO. AND TITLE OF EXAMINATION(S) FOR WHICH CREDIT
IS CLAIMED
2
TO BE COMPLETED BY VETERANS BENEFITS ADMINISTRATION:
Please return original to: Recruitment and Selection Unit
Westchester County Department of Human Resources
148 Martine Avenue, Suite 100, White Plains, NY 10601
DATE:
CLAIM NO.
REGIONAL V.A. OFFICE
YES
NO
a.
Does the above-named veteran now have war-disability? If “Yes” Please enter date
disability was sustained. Date:
If "Yes" please enter date of VA Disability Determination:
YES NO
Is this veteran receiving disability payments from the V.A. for such disability?
b.
State percentage of such disability.
c.
%
Describe the disability.
d.
Date of last medical examination by the V.A. Medical Officer in
e.
Connection with such disability:
[IF LESS THAN ONE YEAR AGO DO NOT ANSWER ( f) and
(g.).]
YES NO
f.
Does the V.A. state affirmatively that a permanent stabilized condition of disability
exists to an extent of 10% or more, even though claimant has not been examined by
V.A. Medical Officer within one year?
Date of next examination by the V.A.
g.
h.
Remarks:
Signature of Adjudication Officer:
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