Va Form 21-526c - Pre-Discharge Compensation Claim
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2OMB Control No. 2900-0743
Respondent Burden: 15 minutes
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
PRE-DISCHARGE COMPENSATION CLAIM
(For use only with Benefits Delivery at Discharge (BDD) or Quick Start Claims)
IMPORTANT: Please read the Privacy Act and Respondent Burden on the back before completing the form.
THIS FORM WILL BE USED FOR (CHECK ONLY ONE)
Benefits Delivery at Discharge (BDD) CLAIMS
Quick Start Claims
SECTION I: TO BE COMPLETED BY SERVICE MEMBER
1. SERVICE MEMBER NAME (Last, first, middle)
2. PLACE OF SEPARATION
3. SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM,DD,YYYY)
5. SEX
MALE
FEMALE
6B. TELEPHONE NUMBERS (Include Area Code)
6A. CURRENT ADDRESS
Daytime
Street address, rural route, or P.O. Box
Apt. number
Evening
Cell phone
City
State
ZIP Code
Country
7A. WORK E-MAIL ADDRESS (If applicable)
7B. PERSONAL E-MAIL ADDRESS (If applicable)
8A. FORWARDING ADDRESS
8B. TELEPHONE NUMBER
9A. NAME AND RELATIONSHIP OF NEXT
9B. ADDRESS OF NEXT OF KIN
9C. TELEPHONE NUMBER
OF KIN
OF NEXT OF KIN
10A. HAVE YOU EVER FILED A CLAIM WITH VA?
10B. VA FILE NUMBER
YES
NO
(If "Yes," provide your file number in Item 10B)
11. WHAT DISABILITIES ARE YOU CLAIMING? SUBMIT ADDITIONAL SUPPORTING STATEMENTS AND INFORMATION CONCERNING YOUR
CLAIMED DISABILITIES ON VA FORM 21-4138, STATEMENT IN SUPPORT OF CLAIM, AVAILABLE AT
IMPORTANT: If claiming dependents, please attach a completed VA Form 21-686c, Declaration of Status of Dependents,
available at
SECTION II: SERVICE INFORMATION
12A. DID YOU SERVE UNDER ANOTHER NAME?
12B. PLEASE LIST OTHER NAME(S) YOU SERVED UNDER
YES
(If "Yes," go to Item 12B)
NO
(If "No," go to Item 13A)
13A. I ENTERED THIS CURRENT PERIOD OF
13B. BRANCH OF SERVICE
13C. ANTICIPATED DATE
13D. DID YOU SERVE IN A
ACTIVE SERVICE ON (MM,DD,YYYY)
OF RELEASE FROM
COMBAT ZONE SINCE
ACTIVE DUTY
9-11-2001?
NO
YES
mo
day
yr
14B. DATE OF ACTIVATION (MM,DD,YYYY)
14A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
AUTHORITY OF TITLE 10, U.S.C.?
YES
NO
(If "Yes," provide date of activation in Item 14B)
mo
day
yr
15A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?
15B. WHAT IS THE TELEPHONE
NUMBER OF YOUR CURRENT
UNIT? (Include Area Code)
16A. DO YOU HAVE ADDITIONAL PERIODS OF ACTIVE SERVICE?
16B. I PREVIOUSLY ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
YES
(If "Yes," go to Item 16B)
mo
day
yr
NO
(If "No," go to Item 17A)
VA FORM
21-526c
JUL 2009
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