Va Form 21-8940 - Veteran'S Application For Increased Compensation Based On Unemployability Page 2

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SECTION III - SCHOOLING AND OTHER TRAINING

22. EDUCATION (Check highest year completed)

GRADE SCHOOL

HIGH SCHOOL

COLLEGE

23A. DID YOU HAVE ANY OTHER EDUCATION AND TRAINING BEFORE YOU WERE TOO DISABLED TO WORK?

(If "Yes," complete Items 23B, and 23C)

YES

23C. DATES OF TRAINING

23B. TYPE OF EDUCATION OR TRAINING

BEGINNING

COMPLETION

24A. HAVE YOU HAD ANY EDUCATION AND TRAINING SINCE YOU BECAME TOO DISABLED TO WORK?

(If "Yes," complete Items 24B, and 24C)

YES

24C. DATES OF TRAINING

24B. TYPE OF EDUCATION OR TRAINING

BEGINNING

COMPLETION

25. REMARKS

SECTION IV - AUTHORIZATION, CERTIFICATION, AND SIGNATURE

AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the person or entity, including but not limited to any organization, service provider, employer, or

Government agency, to give the Department of Veterans Affairs any information about me except protected health information, and I waive any privilege which makes the

information confidential.

CERTIFICATION OF STATEMENTS: I CERTIFY THAT as a result of my service-connected disabilities, I am unable to secure or follow any substantially gainful

occupation and that the statements in this application are true and complete to the best of my knowledge and belief. I understand that these statements will be considered in

determining my eligibility for VA benefits based on unemployability because of service-connected disability.

I UNDERSTAND THAT IF I AM GRANTED SERVICE-CONNECTED TOTAL DISABILITY BENEFITS BASED ON MY UNEMPLOYABILITY, I MUST

IMMEDIATELY INFORM VA IF I RETURN TO WORK. I ALSO UNDERSTAND THAT TOTAL DISABILITY BENEFITS PAID TO ME AFTER I BEGIN WORK

MAY BE CONSIDERED AN OVERPAYMENT REQUIRING REPAYMENT TO VA.

26. SIGNATURE OF CLAIMANT

28. TELEPHONE NUMBER(S) (Include Area Code)

27. DATE SIGNED

A. DAYTIME

B. NIGHTTIME

WITNESS TO SIGNATURE OF CLAIMANT IF MADE "X" MARK. NOTE: Signature made by mark must be witnessed by two persons to whom the person making

the statement is personally know and the signature and address of such witnesses must be shown below.

29A. SIGNATURE OF WITNESS

29B. ADDRESS OF WITNESS

30A. SIGNATURE OF WITNESS

30B. ADDRESS OF WITNESS

PENALTY: The law provides sever penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact,

knowing it to be false or for the fraudulent acceptance of any payment to which you are not entitled.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or

Title 38, Code of Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the

collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA

benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education,

and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits.

Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38, U.S.C. 5101(c)(1). VA will not deny an individual

benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.

The requested information is considered relevant and necessary to determine maximum benefits provided under the law. The responses you submit are considered

confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine eligibility for individual unemployment (38 U.S.C., 1163). Title 38, United States Code, allows us to

ask for this information. We estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete this form. VA cannot

conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this

number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at If desired, you can call

1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-8940, JUN 2011