Va Form 21-526e - Application For Disability Compensation And Related Compensation Benefits Template

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OMB Control No. 2900-0747
Respondent Burden: 25 minutes
Expiration Date; 11/30/2017
Department of Veterans Affairs
APPLICATION FOR DISABILITY COMPENSATION
AND RELATED COMPENSATION BENEFITS
VA DATE STAMP
{DO NOT WRITE IN THIS SPACE)
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 10 before completing the form.
SECTION I: IDENTIFICATION AND CLAIM INFORMATION
1. VETERAN/SERVICE MEMBER NAME (First, Middle Initial Last)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. HAVE YOU EVER FILED A CLAIM WITH VA?
n VF<?
F1 wn
VfYes," provide your file
• YES
• NO
numberinI[em4)
4. VA FILE NUMBER
5. DATE OF BIRTH (MM.DD.YYYY)
Month
Day
Year
6. SEX
Q] MALE
Q FEMALE
7. VETERAN'S SERVICE NUMBER (If applicable)
8A. ARE YOU CURRENTLY HOMELESS OR AT RISK
OF BECOMING HOMELESS?
| j YES
D NO (If "Yes,"complete Items 8B & 8C)
8B. POINT OF CONTACT (Name of
person that VA can contact in order
to get in touch with you)
8C. POINT OF CONTACT TELEPHONE NUMBER
(Include Area Code)
9A. SERVICE (Check all that apply)
• ARMY
• NAVY
• MARINE CORPS
• AIR FORCE
• COAST GUARD
9B. COMPONENT (Check all that apply)
• ACTIVE
Q RESERVES • NATIONAL GUARD
10A. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province
City
Country
ZIP Code/Postal Code
10B. FORWARDING ADDRESS AND EFFECTIVE DATE (Provide the date you will be living at this address)
No, &
Street
Apt./Unit Number
State/Province
City
Country
ZIP Code/Postal Code
EFFECTIVE DATE:
Month
Day
Year
11. PREFERRED TELEPHONE NUMBER
12B. ALTERNATE E-MAIL ADDRESS (If applicable)
12A. PREFERRED E-MAIL ADDRESS (If applicable)
FEB?O
R
I6 21-526EZ
SUPERSEDES VA FORM 21-526EZ, MAY 2015,
WHICH WILL NOT BE USED.
Page 7

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