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?
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
(If "Yes," answer Items 3b and 3c also)
3c.What is the name and complete
3b. Tell us the dates of the recent
mailing address of the facility or
hospitalization or care
Attach current medical
evidence showing that
you are permanently
and totally disabled.
4a. Are you now employed?
4b. When did you last work?
Note: If you are a
veteran who is age
65 or older or
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?
becoming totally disabled?
you DO NOT have to
submit medical evidence
with your application.
(If "Yes," answer Item 4d and 4e also)
Are you still self-employed?
What kind of work do you do now?
(If "Yes," answer Item 4f also)
Have you claimed or are you
4h. Circle the highest year of education
receiving disability benefits from the Social
Security Administration (SSA)?
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 over 4
4i. List the other training or experience you have and any certificates that you hold.
21-526, Part D