Va Form 21-0304 - Application For Benefits For Certain Children With Disabilities Born Of Vietnam And Certain Korea Service Veterans

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OMB Approved 2900-0572
Respondent Burden: 10 minutes
APPLICATION FOR BENEFITS FOR CERTAIN
CHILDREN WITH DISABILITIES BORN OF
VIETNAM AND CERTAIN KOREA SERVICE VETERANS
Privacy Act Notice: The 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 5, Code of Federal Regulations 1.526 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 Compensation, Pension, Education,
and Rehabilitation Records - VA, and 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 USC 5101 (c) (1). The VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect.
Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to
receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department
of Veterans Affairs.
Respondent Burden: We need this information to determine eligibility for benefits for children with certain disabilities who are born of Vietnam veterans and certain
Korea Service veterans (38 U.S.C. chapter 18). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 10
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.
NOTE - After completing the form mail to: VA Regional Office, Veterans Service Center (339/21), Box 25126, Denver, CO 80225
(First, middle, last)
(If available)
1. NAME OF CLAIMANT - CHILD
2. SOCIAL SECURITY NUMBER OF CLAIMANT - CHILD
(City and State)
3. CLAIMANT - CHILD'S DATE OF BIRTH
4. CLAIMANT - CHILD'S PLACE OF BIRTH
(Include number and street or rural route, city or P.O., State and ZIP Code)
5. ADDRESS OF CLAIMANT - CHILD
(Include Area Code)
6. TELEPHONE NUMBER OF CLAIMANT - CHILD
7. NAME(S) OF NATURAL PARENT(S) (Please provide information for both)
(First, middle, last)
(First, middle, last)
A. FATHER
B. MOTHER
8. ADDRESS, TELEPHONE NUMBER AND VETERAN STATUS OF NATURAL PARENT(S)
(Include number and street or rural route, city or P.O., State and
(Include number and street or rural route, city or P.O., State and
A. FATHER
B. MOTHER
ZIP Code)
ZIP Code)
C. VIETNAM SERVICE?
D. VIETNAM SERVICE?
(If "Yes", provide dates in 8E)
(If "Yes", provide dates in 8F)
YES
NO
YES
NO
E. PLEASE PROVIDE THE DATES THAT CHILD'S FATHER WAS IN VIETNAM
F. PLEASE PROVIDE THE DATES THAT CHILD'S MOTHER WAS IN VIETNAM
FROM
TO
FROM
TO
9. SOCIAL SECURITY NUMBER(S) OF NATURAL PARENT(S)
A. FATHER
B. MOTHER
10. VA CLAIM NUMBER(S) OF NATURAL PARENT(S) (If veteran previously applied to VA for any benefit)
A. FATHER
B. MOTHER
VA FORM
21-0304
SUPERSEDES VA FORM 21-0304, MAR 2004,
(Continue on Reverse)
SEP 2006
WHICH WILL NOT BE USED.

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