Looking for a Va Form 21-526ez Templates? Download it for free!

VETERANS SOCIAL SECURITY NO.

NOTE: IF YOU WISH TO CLAIM ANY OF THE FOLLOWING, COMPLETE AND ATTACH THE REQUIRED FORM(S) AS STATED BELOW

(VA forms are available at

For:

Required Form(s):

Dependents

VA Form 21-686C and, if claiming a child aged 18-23 years and in school, VA Form 21-674

Individual Unemployability

VA Form 21-8940 and 21-4192

Post-Traumatic Stress Disorder

VA Form 21-0781 and 21-0781a

Specially Adapted Housing or Special Home Adaptation

VA Form 26-4555

Auto Allowence

VA Form 21-4502

Veteran/Spouse Aid and Attendance benefits

VA Form 21-2680 or, if based on nursing home attendance, VA Form 21-0779

SECTION II: SERVICE INFORMATION

15A. DID YOU SERVE UNDER ANOTHER NAME?

I | YES

(If "Yes," complete Item 15B)

Q NO (If "No," skip to Item I6A)

15B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER:

16A. MOST RECENT ACTIVE SERVICE ENTRY DATE

(MM.DD.YYYY)

Month

Day

Year

16B. RELEASE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE SERVICE

(MM.DD.YYYY)

Month

Day

Year

16C. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?

• YES

• NO

16D. PLACE OF LAST OR ANTICIPATED SEPARATION

17A. ARE YOU CURRENTLY SERVING OR HAVE YOU EVER SERVED IN

THE RESERVES OR NATIONAL GUARD?

• YES

Q NO

(If "Yes," complete Items 17B thru 17F)

(If "No," skip to Item ISA)

17B. COMPONENT

NATIONAL

L-J GUARD

Q RESERVES

17C. OBLIGATION TERM OF SERVICE

Month

Day

From:

To:

Year

170. CURRENT OR LAST ASSIGNED NAME AND ADDRESS OF UNIT:

17E. CURRENT OR ASSIGNED PHONE

NUMBER OF UNIT (Include Area

Code)

17F. ARE YOU CURRENTLY

RECEIVING INACTIVE DUTY

TRAINING PAY?

• YES

• NO

18A. ARE YOU CURRENTLY ACTIVATED ON FEDERAL

ORDERS WITHIN THE NATIONAL GUARD OR

RESERVES?

• YES

Q NO

(if "Yes," complete Items I8B & ISC)

18B. DATE OF ACTIVATION:

(MM.DD.YYYY)

Month

Day

Year

18C. ANTICIPATED SEPARATION DATE:

(MM,DD,YYYY)

Day

Year

Month

19A. HAVE YOU EVER BEEN A PRISONER OF WAR?

• YES

• NO

(If "Yes," complete Item I9B)

19B. DATES OF CONFINEMENT (MM.DD.YYYY)

From:

Month

Day

Year

To:

Month

Day

Year

SECTION III: SERVICE PAY

20A. DID/DO YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE/RETIRED PAY?

I | YES

Q NO

(If "Yes," complete Items 20B and 20C)

20B. LIST AMOUNT (If known)

20C. LIST TYPE (If known)

IMPORTANT: Submission of this application constitutes an election of VA compensation in lieu of military retired pay if it is determined you are entitled to both

benefits. If you are entitled to receive military retired pay, your retired pay may be reduced by the amount of any VA compensation that you are awarded. VA will

notify the Military Retired Pay Center of all benefit changes. Receipt of military retired pay or Voluntary Separation Incentive (VSI) and VA compensation at the same

time may result in an overpayment, which may be subject to collection. However, if you do not want to receive VA compensation in lieu of military retired pay, you

should check the box in Item 21. Please note that if you check the box in Item 21, you will not receive VA compensation, if granted.

| | 21.1 want military retired pay instead of VA compensation

IMPORTANT: You may elect to keep the training pay for inactive duty training days you received from the military service department. However, to be legally

entitled to keep your training pay, you must waive VA benefits for the number of days equal to the number of days for which you received training pay. In most

instances, it will be to your advantage to waive your VA benefits and keep your training pay.

If you waive VA benefits to receive training pay by checking the box in Item 22, VA will adjust your VA award to withhold future benefits equal to the total number of

inactive duty for training days waived and at the monthly rate in effect for the fiscal year period for which you received training pay. Your normal VA rate will be

restored when the sufficient numbers of days' benefits have been withheld.

| [ 22.1 elect to waive VA benefits for the days I accrued inactive duty training pay in order to retain my inactive duty training pay.

VA FORM 21-526EZ, FEB 2016

Page 9