Form Sdat-4b1 - Application For Exemption For Surviving Spouses Of Disabled Veterans Receiving Dic Benefits Page 2

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SDAT APPLICATION FOR EXEMPTION FOR SURVIVING SPOUSES OF DISABLED VETERANS RECEIVING DIC BENEFITS (continued)
TO BE COMPLETED BY THE VETERANS ADMINISTRATION
The United States Department of Veteran Affairs (VA) hereby certifies that the above named veteran:
(1) Prior to his/her death, was declared by the VA to have a service-connected disability, which was not incurred
through misconduct. Yes ____
No ____. If yes, the said disability was _______% disabling, permanent in
character, and reasonably certain to have continued throughout the life of said veteran; and that the said veteran
had been receiving disability payments as allowed for reasons of _______% disability, or _______%
unemployability.
(2)
After his/her death, was the veteran declared by the VA to be 100% disabled? Yes ____
No __
(3)
Is the veteran’s surviving spouse receiving Dependency and Indemnity Compensation (DIC) from the VA?
Yes ____ No ____
(4)
Specify the nature of the service connected disability or illness of the veteran that entitles the surviving spouse
to receive DIC:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________
_______________________________________________
Effective Date
Adjudication/Service Officer
___________________________________________
_____________________________________________
Address
City
State
Zip Code
___________________________________________
_____________________________________________
Phone
Date
(FOR SDAT OFFICE USE ONLY)
COMMENTS:
_______________________________________________________________________________________
_______________________________________________________________________________________
□
□
New Application
Re-application
Code No. ___________________
□
□
Approved
Disapproved
Effective: ____________________
Land _________________
Improvement _________________
Total ___________________
_________________________________________________
___________________________________
Supervisor’s Signature
Date
THIS APPLICATION IS NOT OPEN FOR PUBLIC INSPECTION
SDAT – 4B1 (5/09)
2

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