Va Form 21-527ez - Application For Pension - Department Of Veteran Affairs
Download a blank fillable Va Form 21-527ez - Application For Pension - Department Of Veteran Affairs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 21-527ez - Application For Pension - Department Of Veteran Affairs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4OMB Control No. 2900-0747
Respondent Burden: 25 minutes
Expiration Date: 4/30/2016
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
APPLICATION FOR PENSION
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 8 before completing the form.
SECTION I: VETERAN'S PERSONAL INFORMATION
(MUST COMPLETE)
1. VETERAN'S NAME (Last, first, middle)
2. SOCIAL SECURITY NUMBER
3. DATE OF BIRTH (MM,DD,YYYY)
4. SEX
5. HAVE YOU EVER FILED A CLAIM WITH VA?
6. VA FILE NUMBER
MALE
FEMALE
YES
NO
(If "Yes," provide your file number in Item 6)
7A. MAILING ADDRESS
7B. TELEPHONE NUMBERS (Include Area Code)
DAYTIME
(
)
Street address, rural route, or P.O. Box
Apt. number
EVENING
(
)
CELL PHONE
City
State
ZIP Code
Country
(
)
8A. PREFERRED E-MAIL ADDRESS (If applicable)
8B. ALTERNATE E-MAIL ADDRESS (If applicable)
9. WHAT DISABILITY(IES) PREVENTS YOU FROM WORKING?
A. DISABILITY(IES)
B. DATE DISABILITY(IES) BEGAN
10. LIST ANY VA MEDICAL CENTERS WHERE YOU RECEIVED TREATMENT FOR YOUR
CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES
A. NAME AND LOCATION OF VA MEDICAL CENTER
B. DATE(S) OF TREATMENT
SECTION II: VETERAN'S SERVICE INFORMATION
(MUST COMPLETE)
11A. DID YOU SERVE UNDER ANOTHER NAME?
11B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER
YES
(If "Yes," complete Item 11B)
NO
(If "No," skip to Item 12A)
12A. I ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
12B. BRANCH OF SERVICE
12C. RELEASE DATE OR ANTICIPATED DATE
OF RELEASE FROM ACTIVE SERVICE
12E. PLACE OF LAST OR ANTICIPATED SEPARATION
12D. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?
YES
NO
13A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
13B. DATE OF ACTIVATION (MM,DD,YYYY)
AUTHORITY OF TITLE 10, U.S.C. (National Guard)?
YES
NO
(If "Yes," provide date of activation in Item 13B)
14A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?
14B. WHAT IS THE TELEPHONE NUMBER OF
YOUR CURRENT UNIT? (Include Area Code)
(
)
15A. HAVE YOU EVER BEEN A PRISONER OF WAR?
15B. DATES OF CONFINEMENT ON (MM,DD,YYYY)
YES
NO
(If "Yes," complete Item 15B)
From:
To:
(If "No," skip to Item 16A)
16A. DID YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE
16C. LIST TYPE (If known)
16B. LIST AMOUNT (If known)
RETIRED PAY?
(If "Yes," complete Items 16B and 16C)
$
YES
NO
SECTION III: VETERAN'S WORK HISTORY
)
(MUST COMPLETE
NOTE: In the table below, tell us about all of your employment, including self-employment, for one year before you became disabled to the present.
17E. HOW MANY
17F. WHAT WERE
17A. WHAT WAS THE NAME AND ADDRESS OF
17B. WHAT WAS
17C. WHEN DID
17D. WHEN DID
DAYS WERE LOST
YOUR TOTAL
YOUR EMPLOYER?
YOUR JOB TITLE?
YOUR JOB BEGIN?
YOUR JOB END?
DUE TO DISABILITY?
ANNUAL EARNINGS?
$
$
VA FORM
21-527EZ
SUPERSEDES VA FORM 21-527EZ, AUG 2011,
Page 5
JUN 2014
WHICH WILL NOT BE USED.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21-4182 - Application For Dependency And Indemnity Compensation Or Death Pension (including Accrued Benefits And Death Compensation Where Applicable) From The Department Of Veterans Affairs
Legal
Related Categories
Parent category: Legal