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VETERANS SOCIAL SECURITY NO.

SECTION IV: DIRECT DEPOSIT INFORMATION

The Department of Treasury requires aii Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. Please attach a voided personal

check or deposit slip or provide the information requested below in Items 23, 24 and 25 to enroll in direct deposit. If you do not have a bank account, you must receive

your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard you must apply at or by telephone at

1-800-333-1795. If you elect not to enroll, you must contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They will

encourage your participation in EFT and address any questions or concerns you may have.

23. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA)

• CHECKING

• SAVINGS

Q ' CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL

Account No.:

INSTITUTION OR CERTIFIED PAYMENT AGENT

24. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank

where you want your direct deposit)

25. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the

bottom left of your check)

SECTION V: CLAIM CERTIFICATION AND SIGNATURE

I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I authorize any

person or entity, including but not limited to any organization, service provider, employer, or government agency, to give the Department of Veterans Affairs any

information about me, and I waive any privilege which makes the information confidential.

1 certify I have received the notice attached to this application titled, Notice to Veteran/Service Member ofEvidence Necessary to Substantiate a Claim for Veterans

Disability Compensation and Related Compensation Benefits.

I certify I have enclosed all the information or evidence that will support my claim, to include an identification of relevant records available at a Federal facility such as

a VA medical center; OR, I have no information or evidence to give VA to support my claim; OR, I have checked the box in Item 26, indicating that I do not want my

claim considered for rapid processing in the Fully Developed Claim (FDC) Program because I plan to submit further evidence in support of my claim.

ALTERNATE SIGNER: By signing on behalf of the claimant, I certify that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act

on behalf of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a spouse or other

relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND, that the claimant is under the age

of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to certify that the statements made on the form are

true and complete; OR, is physically unable to sign this form.

I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that VA may request

further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant if necessary. Examples of evidence

which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN); a certificate or order from a court with competent jurisdiction

showing your authority to act for the claimant with a judge's signature and date/time stamp; copy of documentation showing appointment of fiduciary; durable power of

attorney showing the name and signature of the claimant and your authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement

from an institution or person responsible for the care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such

authorization.

26. The FDC Program is designed to rapidly process compensation or pension claims received with the evidence necessary to decide the claim. VA will automatically

consider a claim submitted on this form for rapid processing under the FDC Program. Check the box below ONLY if you DO NOT want your claim considered for

rapid processing under the FDC Program because you plan on submitting further evidence in support of your claim.

I I I DO NOT want my claim considered for rapid processing under the FDC Program because 1 plan to submit further evidence in support of my claim.

27A. VETERAN/SERVICE MEMBER/ALTERNATE SIGNER SIGNATURE (REQUIRED)

27B. DATE SIGNED

SECTION VI: WITNESSES TO SIGNATURE

28A. SIGNATURE OF WITNESS (If veteran signed above using an "X")

28B. PRINTED NAME AND ADDRESS OF WITNESS

29A. SIGNATURE OF WITNESS (If veteran signed above using an "X")

29B. PRINTED NAME AND ADDRESS OF WITNESS

SECTION VII; POWER OF ATTORNEY (POA) SIGNATURE

I certify that the claimant has authorized the undersigned representative to file this supplemental claim on behalf of the claimant and that the claimant is aware and

accepts the information provided in this document. I certify that the claimant has authorized the undersigned representative to state that the claimant certifies the truth

and completion of the information contained in this document to the best of claimant's knowledge.

NOTE: A POA's signature will not be accepted unless at the time of submission of this claim a valid VA Form 21-22, Appointment of Veterans Service Organization as

Claimant's Representative, or VA Form 21-22a, Appointment of Individual As Claimant's Representative, indicating the appropriate POA is of record with VA.

30A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE

30B. DATE SIGNED

PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The resjionses you submit are considered confidential (38 U.S.C. 5703), VA may disclose the

information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28,

Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records • VA, published in the Federal Register. The requested information is considered relevant and necessaty to determine maximum

benefits under the law. Information submitted is subjert to verification through computer matching programs with other agencies. VA may make a "routine use'

disclosure for: civil or criminal law enforcement, congressional

communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which die United States is a party or has an interest, the administration of VA programs and delivery of

VA benefits, verification of identity and status, and personnel administration. Your obligation to respond is required in order to obtain or retain benefits. Information that you furnish may be utilized in computer matching

programs with other Federal or State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit

program administered by the Department of Veterans Affairs. Social Security information: You are required to provide the Social Security number requested under 38 U.S.C. Sl0l(c)(l). VA may disclose Social Security

numbers as authorized under the Privacy Act, and, specifically may disclose them for purposes stated above.

RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 25

minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to

a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at ww\v.rc«infn.^<iv/piihlii'/il<i/PltAMfllii. If desired, you can call 1-800-827-1000 to get

information on where fa send comments or suggestions about (his form.

VA FORM 21-526EZ, FEB 2016

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