AUTHORIZATION FOR DISABILITY RECORD
Department of Human Resources
148 Martine Avenue, Suite 100
White Plains, New York 10601
TO BE COMPLETED BY DISABLED VETERAN:
To Manager, Department Of Veterans Affairs
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.
PRINT FULL NAME
VA CLAIM NO.
NO. AND TITLE OF EXAMINATION(S) FOR WHICH CREDIT
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
REGIONAL V.A. OFFICE
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:
Is this veteran receiving disability payments from the V.A. for such disability?
State percentage of such disability.
Describe the disability.
Date of last medical examination by the V.A. Medical Officer in
Connection with such disability:
[IF LESS THAN ONE YEAR AGO DO NOT ANSWER ( f) and
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.
Signature of Adjudication Officer: