VA DISABILITY COMPENSATION CLAIM

Supporting Statement and Evidence Summary

SECTION 1: VETERAN IDENTIFICATION

Full Legal Name:
[________________________________]

VA File Number (if known): [________________________________]

Social Security Number: [___-__-____]

Date of Birth: [__/__/____]

Current Mailing Address:
Street: [________________________________]
City: [________________] State: [____] Zip: [________]

Telephone Numbers:
Primary: [(___)___-____]
Alternate: [(___)___-____]

Email Address: [________________________________]

Preferred Contact Method:
☐ Mail ☐ Telephone ☐ Email

SECTION 2: MILITARY SERVICE INFORMATION

A. Service Periods

Total Active Duty Time: [____] years [____] months

Reserve/National Guard Service:
☐ Yes - Unit: [________________________________]
☐ No

B. Service Information

Final Rank/Grade: [________________________________]

Military Occupational Specialty (MOS/Rating): [________________________________]

Duty Stations:
| Station | Dates | Country |
|---------|-------|---------|
| [________________________________] | [__/__/____] to [__/__/____] | [________] |
| [________________________________] | [__/__/____] to [__/__/____] | [________] |
| [________________________________] | [__/__/____] to [__/__/____] | [________] |

C. Combat/Hazardous Duty

☐ Combat service: [Location/Dates: ________________________________]
☐ Served in Southwest Asia (Gulf War presumptives may apply)
☐ Served in Vietnam (Agent Orange presumptives may apply)
☐ Exposed to burn pits (PACT Act presumptives may apply)
☐ Exposed to radiation
☐ Prisoner of War status
☐ Camp Lejeune water contamination exposure
☐ None of the above

Combat Awards/Decorations:
☐ Purple Heart
☐ Combat Infantry Badge (CIB)
☐ Combat Action Badge (CAB)
☐ Combat Action Ribbon (CAR)
☐ Other: [________________________________]

SECTION 3: REPRESENTATIVE INFORMATION

☐ I am filing this claim without representation

☐ I am represented by a Veterans Service Organization (VSO):
Organization Name: [________________________________]
Representative Name: [________________________________]
Contact Information: [________________________________]

☐ I am represented by an attorney:
Attorney Name: [________________________________]
Firm: [________________________________]
VA Accreditation Number: [________________________________]
Contact Information: [________________________________]

☐ I am represented by a claims agent:
Agent Name: [________________________________]
VA Accreditation Number: [________________________________]

SECTION 4: INTENT TO FILE

Have you filed an Intent to File (VA Form 21-0966)?

☐ Yes - Date filed: [__/__/____]
☐ No - I understand this may affect my effective date

Claimed Effective Date: [__/__/____]

Basis for Effective Date:
☐ Date of Intent to File
☐ Date of claim
☐ Date of increase in severity
☐ One year from date of discharge
☐ Liberalizing law change
☐ Clear and unmistakable error (CUE)
☐ Other: [________________________________]

SECTION 5: CONDITIONS CLAIMED

A. Service-Connected Conditions

List all conditions for which you are claiming service connection:

Condition 1:

Diagnosis/Condition: [________________________________]
Body Part/System: [________________________________]
Date Condition Began: [__/__/____]
ICD Code (if known): [________________________________]

Claim Type:
☐ Direct service connection - Condition occurred during or was caused by service
☐ Secondary service connection - Condition caused by or aggravated by already service-connected condition
Related to service-connected: [________________________________]
☐ Aggravation - Pre-existing condition worsened beyond natural progression
☐ Presumptive condition (Agent Orange, Gulf War, PACT Act, etc.)

In-Service Event, Injury, or Exposure:
[________________________________]
[________________________________]
[________________________________]

Condition 2:

Diagnosis/Condition: [________________________________]
Body Part/System: [________________________________]
Date Condition Began: [__/__/____]

Claim Type:
☐ Direct ☐ Secondary ☐ Aggravation ☐ Presumptive

In-Service Event, Injury, or Exposure:
[________________________________]
[________________________________]

Condition 3:

Diagnosis/Condition: [________________________________]
Body Part/System: [________________________________]
Date Condition Began: [__/__/____]

Claim Type:
☐ Direct ☐ Secondary ☐ Aggravation ☐ Presumptive

In-Service Event, Injury, or Exposure:
[________________________________]
[________________________________]

(Attach additional pages as needed)

SECTION 6: IN-SERVICE EVENTS AND EVIDENCE

A. Service Treatment Records (STRs)

☐ I have copies of my Service Treatment Records
☐ VA should obtain my Service Treatment Records
☐ My Service Treatment Records may be incomplete due to: [________________________________]

Relevant STR Entries:

B. Personnel Records

☐ I am submitting copies of relevant personnel records
☐ My DD-214 shows: [________________________________]
☐ Performance evaluations document: [________________________________]

C. Buddy Statements

☐ I am submitting buddy/lay statements from fellow service members
☐ Statements attached from:
[________________________________]
[________________________________]

SECTION 7: POST-SERVICE MEDICAL EVIDENCE

A. VA Treatment Records

☐ I receive treatment at VA facilities
☐ VA should obtain my records from the following VA facilities:

B. Private Medical Records

☐ I am submitting private medical records
☐ I authorize VA to obtain records from the following providers:
(VA Form 21-4142 attached for each provider)

C. Nexus Letters/Medical Opinions

☐ I am submitting a medical nexus opinion from: [________________________________]
The opinion states: [________________________________]

☐ I am submitting a Disability Benefits Questionnaire (DBQ) completed by: [________________________________]

SECTION 8: IMPACT ON DAILY LIFE AND WORK

A. Functional Impairment

Describe how each claimed condition affects your daily activities:

[________________________________]
[________________________________]
[________________________________]
[________________________________]

B. Employment Impact

Current Employment Status:
☐ Employed full-time
☐ Employed part-time
☐ Unemployed
☐ Retired
☐ Unable to work due to disabilities (TDIU consideration)

If employed:
Occupation: [________________________________]
Employer: [________________________________]
Work limitations due to condition(s): [________________________________]

If unemployed due to disabilities:
Last date worked: [__/__/____]
Reason unable to work: [________________________________]
☐ I am claiming Total Disability based on Individual Unemployability (TDIU)

C. Medications

SECTION 9: PRESUMPTIVE CONDITIONS

A. PACT Act Presumptives (Toxic Exposure)

☐ I served in a location with known toxic exposure (check all that apply):

Burn Pit Exposure:
☐ Afghanistan ☐ Iraq ☐ Kuwait ☐ Saudi Arabia
☐ Djibouti ☐ Jordan ☐ Syria ☐ Other: [________]
Dates of service: [________________________________]

Presumptive Conditions Claimed:
☐ Asthma diagnosed after service
☐ Head, neck, or respiratory cancer
☐ Chronic rhinitis/sinusitis
☐ Constrictive bronchiolitis
☐ Interstitial lung disease
☐ Glioblastoma
☐ Other PACT Act condition: [________________________________]

B. Agent Orange Presumptives

☐ I served in Vietnam, Korea DMZ, Thailand, or other qualifying location
Location: [________________________________]
Dates: [________________________________]

☐ I am claiming the following presumptive condition:
[________________________________]

C. Gulf War Presumptives

☐ I served in Southwest Asia theater of operations
☐ I have a qualifying chronic multi-symptom illness
☐ I have a medically unexplained chronic illness

SECTION 10: INCREASED RATING CLAIMS (If Applicable)

☐ This is an original claim (skip this section)
☐ I am claiming an increased rating for already service-connected condition(s)

Currently Service-Connected Conditions:

Reason condition has worsened:
[________________________________]
[________________________________]

Date condition worsened: [__/__/____]

SECTION 11: SUPPORTING DOCUMENTS CHECKLIST

Check all documents you are submitting or requesting VA obtain:

☐ DD-214 (Member 4 copy)
☐ Service Treatment Records
☐ Service Personnel Records
☐ VA Form 21-0966 (Intent to File)
☐ VA Form 21-526EZ (Application)
☐ VA Form 21-4142/4142a (Authorization for Records)
☐ VA Form 21-4138 (Statement in Support)
☐ Private medical records
☐ Disability Benefits Questionnaire (DBQ)
☐ Nexus letter/medical opinion
☐ Buddy statements/lay evidence
☐ Employment records
☐ Social Security Administration records
☐ Photographs (injuries, scars, etc.)
☐ Other: [________________________________]

SECTION 12: DECLARATION AND SIGNATURE

I certify that the information provided in this claim is true and correct to the best of my knowledge. I understand that:

1. Making false statements is punishable by fine and/or imprisonment (18 U.S.C. § 1001).
2. I must report any changes to VA that may affect my benefits.
3. I authorize VA to obtain necessary evidence to decide my claim.
4. I may be scheduled for Compensation & Pension (C&P) examinations.

Veteran Signature: _________________________________

Printed Name: [________________________________]

Date: [__/__/____]

FILING INSTRUCTIONS

File Online:

VA.gov - www.va.gov/disability/file-disability-claim-form-21-526ez/

File by Mail:

Department of Veterans Affairs
Claims Intake Center
PO Box 4444
Janesville, WI 53547-4444

File in Person:

At your nearest VA Regional Office

File through VSO:

Contact your local VSO representative

IMPORTANT INFORMATION

Effective Date: Generally the date of claim or Intent to File, but may be earlier if claim is filed within one year of discharge.

C&P Examination: VA will likely schedule a Compensation and Pension examination. Attend this appointment - failure to attend may result in claim denial.

Processing Time: Average processing time varies. Check status at VA.gov or call 1-800-827-1000.

Appeals: If you disagree with the decision, you have options under the Appeals Modernization Act (AMA):
- Supplemental Claim (new evidence)
- Higher-Level Review (same evidence, different reviewer)
- Board of Veterans Appeals

END OF VA BENEFITS CLAIM TEMPLATE