Va Form 21-526e - Application For Disability Compensation And Related Compensation Benefits Template Page 2
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4VETERANS SOCIAL SECURITY NO.
13. LIST THE DISABILITY{IES) YOU ARE CLAIMING (If applicable, identify whether a disability is due to a service-connected disability, is due to confinement as a
Prisoner of War, is due to exposure to Agent Orange, Asbestos, Mustard Gas, Ionizing Radiation, or Gulf War Environmental Hazards, or is related to benefits
under 38 U.S.C. 1151).
Please list your contentions below. See the following examples, for more information:
• Example 1: Hearing loss
• Example 2: Diabetes-Agent Orange (exposed 12/72, Da Nang)
• Example 3: Left knee - secondary to right knee
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14. LIST VA MEDICAL CENTER(S) (VAMC) AND DEPARTMENT OF DEFENSE (DOD) MILITARY TREATMENT FACILITIES (MTF) WHERE YOU RECEIVED TREATMENT
AFTER DISCHARGE FOR YOUR CLAIMED DISABILITY(fES) AND PROVtOE TREATMENT DATES:
A. NAME AND LOCATION
B. DATE(S) OF TREATMENT
VA FORM 21-526EZ, FEB 2016
Page 8
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