Va Form 21-526 - Part D - Veterans Application For Compensation And/or Pension printable pdf download

Va Form 21-526 - Part D - Veterans Application For Compensation And/or Pension

VA Form 21-526, Part D: Pension

Use this form to apply for pension. Remember that you must also fill out a VA Form 21-526, Part A: General Information, for

your application to be processed. Be sure to write your name and Social Security number in the space provided on page 4.

1a. What disability(ies) prevent you from

1b. When did the disability(ies) begin?

SECTION

Tell us

working?

about your

disability

and

background

day

Complete this section if

3a. Are you now, or have you recently

2. Are you claiming a special monthly

you are claiming pension

been hospitalized or given outpatient

pension because you need the

or home-based care?

regular assistance of another person,

because of permanent

are blind, nearly blind, or having

and total disability not

severe visual problems, or are

caused by your military

housebound?

Yes

service.

(If "Yes," answer Items 3b and 3c also)

Yes

3c.What is the name and complete

3b. Tell us the dates of the recent

mailing address of the facility or

hospitalization or care

doctor?

Attach current medical

Began

day

evidence showing that

you are permanently

Ended

and totally disabled.

day

4a. Are you now employed?

4b. When did you last work?

Note: If you are a

veteran who is age

Yes

65 or older or

day

determined to be

(If "No," answer Item 4b also)

disabled by the Social

4c. Were you self-employed before

4d. What kind of work did you do?

Security Administration,

becoming totally disabled?

you DO NOT have to

submit medical evidence

Yes

with your application.

(If "Yes," answer Item 4d and 4e also)

4e.

Are you still self-employed?

What kind of work do you do now?

4f.

Yes

(If "Yes," answer Item 4f also)

4g.

Have you claimed or are you

4h. Circle the highest year of education

receiving disability benefits from the Social

you completed:

Security Administration (SSA)?

Grade school

1 2 3 4 5 6 7 8 9 10 11 12

College

Yes

1 2 3 4 over 4

4i. List the other training or experience you have and any certificates that you hold.

VA Form

21-526

JAN 2004

21-526, Part D

Page 1

Va Form 21-526 - Part D - Veterans Application For Compensation And/or Pension

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