Va Form 21-0304 - Application For Benefits For Certain Children With Disabilities Born Of Vietnam And Certain Korea Service Veterans Page 2

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11. IF CHILD IS UNDER AGE 18 WHO HAS CUSTODY, IF OTHER THAN NATURAL PARENT? (Complete Items 11A, 11B & 11C)

A. NAME OF CUSTODIAN/GUARDIAN OF

B. RELATIONSHIP TO CHILD

C. ADDRESS OF CUSTODIAN/GUARDIAN OF CLAIMANT-CHILD

CLAIMANT-CHILD

ADOPTIVE PARENT

GUARDIAN

(Specify)

OTHER

12A. IF CLAIMANT-CHILD IS AGE 18 OR OLDER HAS THE CLAIMANT-CHILD BEEN DECLARED INCOMPETENT?

(If "Yes", complete Items 12B and 12C)

YES

12B. NAME AND ADDRESS OF THE COURT WHICH MADE THE FINDING OF INCOMPETENCY?

12C. NAME AND ADDRESS OF GUARDIAN

13. DISABILITIES CLAIMED

14. NAME AND ADDRESS OF PRIMARY HEALTH CARE PROVIDER FOR THE CLAIMANT

15A. NAME AND PLACE FIRST DIAGNOSED

15B. DATE FIRST DIAGNOSED

16A. NAME(S) AND PLACE(S) OF MOST RECENT TREATMENT

16B. DATE(S) OF TREATMENT

DIRECT DEPOSIT INFORMATION

All federal payments beginning January 2, 1999, must be made by electronic funds transfer (EFT) also called Direct Deposit. Please attach a voided

personal check or deposit slip or provide the information requested below in Items 17A, 17B and 17C to enroll in Direct Deposit. If you do not have a

bank account we will give you a waiver from Direct Deposit, just check the box below in Item 17A. The Treasury Department is working on making

bank accounts available to you. Once these accounts are available, you will be able to decide whether you wish to sign-up for one of the accounts

or continue to receive a paper check. You can also request a waiver if you have other circumstances that you feel would cause you a hardship to be

enrolled in Direct Deposit. You can write to:

Department of Veterans Affairs, 125 S. Main Street, Suite B, Muskogee, OK 74401-7004 and give us a brief description of why you do not wish

to participate in Direct Deposit.

(Please check the appropriate box and provide that account number, if applicable)

17A. ACCOUNT NUMBER

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A

(Please provide account number

)

FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT

CHECKING

SAVINGS

17B. NAME OF FINANCIAL INSTITUTION

17C. ROUTING OR TRANSIT NUMBER

I/We, the undersigned, hereby authorize the hospital or physician shown in Items 14, 15A and 16A to disclose and release to the Department of

Veterans Affairs any information that may have been obtained in connection with the physical examination or treatment of the child.

18B. DATE SIGNED

18A. SIGNATURE(S) OF PARENT/GUARDIAN/ADULT CHILD

(Required)

19B. DATE SIGNED

19A. SIGNATURE OF WITNESS

I/We, the undersigned, declare under penalty of perjury that the information provided is true and correct and that the child named in Item 1 is the natural

child of the person(s) named in Item 7.

(IF AN ADULT)

20B. DATE SIGNED

20A. SIGNATURE OF CHILD

OR PARENT OR GUARDIAN

(IF AVAILABLE OR DIFFERENT)

21B. DATE SIGNED

21A. SIGNATURE OF VIETNAM VETERAN PARENT