Va Form 21-526c - Pre-Discharge Compensation Claim Page 2

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SECTION III: MILITARY RETIRED PAY

17A. WILL YOU RECEIVE RETIRED PAY?

17B. TYPE OF RETIRED PAY?

LONGEVITY

DISABILITY

YES

(If "Yes," complete Item 17B)

TDRL

18A. WILL YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE PAY?

18B. LIST AMOUNT (If known)

18C. LIST TYPE (If known)

(If "Yes," complete Items 18B and 18C)

YES

IMPORTANT: Unless you check the box in Item 19 below, you are telling us that you are choosing to receive VA compensation

instead of military retired pay, if it is determined you are entitled to both benefits. If you are awarded military retired pay prior to

compensation, we will reduce your retired pay by that amount. VA will notify the Military Retired Pay Center of all benefit changes.

If you receive both military retired pay and VA compensation, some of the amount you get may be recouped by VA, or, in the case of

Voluntary Separation Incentive (VSI), by the Department of Defense.

19.

No, I do not want VA compensation in lieu of military retired pay.

SECTION IV: DIRECT DEPOSIT INFORMATION

Generally, all Federal payments are required to 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 20, 21 and 22 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 20. The Treasury Department is working to make

bank accounts available in such situations. 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 a hardship if

you 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.

20. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT

CHECKING

SAVINGS

WITH A FINANCIAL INSTITUTION OR CERTIFIED

PAYMENT AGENT

21. NAME OF FINANCIAL INSTITUTION (Please provide the name of

22. ROUTING OR TRANSIT NUMBER (The first nine numbers located

the bank where you want your direct deposit)

at the bottom left of your check)

SECTION V: CERTIFICATIONS AND SIGNATURE

I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I

authorize any person or entity, including but not limited to any organization, service provider, employer, or government agency, to give the

Department of Veterans Affairs any information about me except protected health information, and I waive any privilege which makes the

information confidential.

23A. YOUR SIGNATURE (Do NOT print)

23B. DATE SIGNED

SECTION VI: WITNESSES TO SIGNATURE

24A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

24B. PRINTED NAME AND ADDRESS OF WITNESS

25A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

25B. PRINTED NAME AND ADDRESS OF WITNESS

PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The responses you submit are considered

confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under the

Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and

Employment Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the

law. Information submitted is subject to verification through computer matching programs with other agencies. VA may make a "routine use" disclosure for: 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. Your obligation to respond is required in order to obtain or retain benefits. 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. Social Security information: You are required to provide the

Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may

disclose them for purposes stated above.

RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. Title 38, United States Code, allows us to ask for this information.

We estimate that you will need an average of 15 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.

VA FORM 21-526c, JUL 2009