21 527Ez – Fill Out and Use This PDF

WHERE TO SEND COMPLETED APPLICATION AND EVIDENCE

When you have completed this application, mail it to the Pension Intake Center listed below. Be sure to attach any materials that support and explain your claim. Also, make a photocopy of your application and all supporting material you submit to

VA before mailing it.

MAIL: Department of Veterans Affairs

Pension Intake Center

P. O. Box 5365

Janesville, WI 53547-5365

The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate! Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are entitled. If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your claim, then VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard Claim Process. See below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional Expedited Process). If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim Process.

WHAT YOU NEED TO DO

You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant evidence not in your possession.

WHEN YOU SHOULD SEND WHAT WE NEED

EVIDENCE TABLES

Veterans Pension

To support a claim for veterans pension, the evidence must show:

1.You met certain minimum active service requirements during a period of war. Generally, those requirements are:

•90 days of service during a period of war; OR

•90 days of consecutive service at least one day of which was during a period of war; OR

•90 days of combined service during more than one period of war:

(Note: If your service began after September 7, 1980, additional length of service requirements may apply, typically requiring two years of continuous service or completion of active-duty obligation)

• OR, any length of active service during a period of war with a discharge due to a service-connected disability

2. You are age 65 or older or are permanently and totally disabled. Your disability or disabilities do not have to be related to your military service. You are considered permanently and totally disabled if medical evidence shows you are:

• A patient in a nursing home for long-term care or medical foster home; OR

• Receiving Social Security disability benefits; OR

• Unemployable due to a disability reasonably certain to continue throughout your lifetime; OR

• Suffering from a disability that is reasonably certain to continue throughout your lifetime that would make it impossible for an average person to follow a substantially gainful occupation; OR

• Suffering from a disease or disorder that VA determines causes persons who have that disease or disorder to be permanently and totally disabled

3. Your income and assets are within established limits. You must report income and assets for:

• Yourself

• Your spouse (unless you live apart and you are estranged and you do not contribute to your spouse's support)

• Your child (unless custody has been legally removed by a court and you do not contribute to your child's support or the child's income is not reasonably available to you).

Assets means the fair market value of all property that an individual owns, including all real and personal property (excluding the value of the primary residence including the residential lot area, not to exceed 2 acres) less the amount of mortgages or other encumbrances specific to the mortgaged or encumbered property). Personal property means the value of personal effects that are in excess of being suitable and consistent with a reasonable mode of life.

EVIDENCE TABLES (Continued)

Veterans Pension with Special Monthly Pension

To support a claim for increased pension eligibility based on the need for aid and attendance, the evidence must show:

• You have corrected visual acuity of 5/200 or less in both eyes; OR

• You have concentric contraction of the visual field to 5 degrees or less; OR

• You are a patient in a nursing home due to mental or physical incapacity; OR

• You need the aid of another person to perform activities of daily living (ADLs), such as bathing or showering, dressing, eating, toileting, and transferring (e.g. getting in and out of bed); OR

• You require regular supervision because you are unsafe if you are left alone due to a mental disorder, OR

• You are bedridden, in that your disability requires that you remain in bed apart from any prescribed course of convalescence or treatment.

To support your claim for increased pension eligibility based on being housebound, the evidence must show:

•You have a single permanent disability evaluated as 100 percent disabling; AND due to such disability, you are permanently and substantially confined to your immediate premises; OR

•You have a single permanent disability evaluated as 100 percent disabled, AND you have an additional disability or disabilities rated 60 percent or higher.

Child Incapable of Self-Support

To support a claim for benefits based on a veteran's child being incapable of self-support, the evidence must show that the child, before his or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.

IMPORTANT

If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognized marriages is

available at http://www.va.gov/opa/marriage/.

FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.

How VA Determines the Effective Date

If we grant your claim, the beginning date of your entitlement will generally be based on when we received your claim.

Special monthly pension may be assigned for disabilities that affect your ability to perform certain activities of daily living or the ability to leave your home. Special monthly pension may be effective from the date the medical evidence first shows entitlement.

For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/.

For additional information or questions contact us online through Ask VA: https://www.va.gov/contact-us

or call us toll-free at 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms.

IMPORTANT

If you wish to make a claim for veterans disability compensation and/or related compensation benefits, use VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. VA forms are available at www.va.gov/vaforms. If you cannot access this form, write the words "Will claim compensation - send VA Form 21-526EZ" in Item 8 or at the top of the attached application and VA will send you the form.

OMB Control No. 2900-0002

Respondent Burden: 25 minutes

Expiration Date: 01/31/2023

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR VETERANS PENSION

IMPORTANT: Please read the Privacy Act and Respondent Burden on page 12 before completing the form.

SECTION I: VETERAN'S PERSONAL INFORMATION (MUST COMPLETE)

1.VETERAN'S NAME (First, Middle Initial, Last)

5.VA FILE NUMBER (If applicable)

6A. MAILING ADDRESS

No. &

Street

7.PREFERRED E-MAIL ADDRESS (If applicable)

8.WHAT DISABILITY(IES) PREVENTS YOU FROM WORKING?

9.LIST ANY VA MEDICAL CENTERS WHERE YOU RECEIVED TREATMENT FOR YOUR CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES

SECTION II: VETERAN'S SERVICE INFORMATION (MUST COMPLETE)

SECTION II: VETERAN'S SERVICE INFORMATION (MUST COMPLETE) (CONTINUED)

11E. PLACE OF LAST SEPARATION

SECTION III: VETERAN'S DISABILITY(IES) AND BACKGROUND (MUST COMPLETE)

NOTE: You do not have to submit medical evidence or list disabilities if you are age 65 or older, unless you are housebound, or require the regular assistance of another person.

14A. ARE YOU CLAIMING SPECIAL MONTHLY PENSION BECAUSE YOU NEED THE REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL PROBLEMS, OR ARE GENERALLY CONFINED TO YOUR IMMEDIATE PREMISES?

15B. NAME AND MAILING ADDRESS OF FACILITY OR DOCTOR

NOTE: In the table below, tell us about all of your employment, including self-employment, for one year before you became disabled to the present.

SECTION III: VETERAN'S DISABILITY(IES) AND BACKGROUND (MUST COMPLETE) (CONTINUED)

18A. WHAT WAS THE NAME AND ADDRESS OF YOUR EMPLOYER?

TELL US ABOUT YOUR MARRIAGE/PREVIOUS MARRIAGES

19B. HOW MANY TIMES HAVE YOU BEEN MARRIED? (Including current marriage)

20A. DATE (MM-DD-YYYY) AND PLACE OF MARRIAGE (City and State or Country)

20B. TO WHOM MARRIED

(First, Middle, Last Name)

20C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

20D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

20E. DATE (MM-DD-YYYY) AND PLACE MARRIAGE ENDED (City and State or Country)

20A. DATE (MM-DD-YYYY) AND PLACE OF MARRIAGE (City and State or Country)

20B. TO WHOM MARRIED

(First, Middle, Last Name)

20C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

20D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

20E. DATE (MM-DD-YYYY) AND PLACE MARRIAGE ENDED (City and State or Country)

20F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 20C, PLEASE EXPLAIN:

SECTION V: CURRENT MARITAL INFORMATION (COMPLETE ONLY IF YOU ARE CURRENTLY MARRIED)

Note - Skip to Section VI if not currently married.

TELL US ABOUT YOUR SPOUSE'S MARRIAGE/PREVIOUS MARRIAGES

21. HOW MANY TIMES HAS YOUR SPOUSE BEEN MARRIED? (Including current marriage)

22A. DATE (MM-DD-YYYY) AND PLACE OF MARRIAGE (City and State or Country)

22B. TO WHOM MARRIED

(First, Middle, Last Name)

22C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

22D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

22E. DATE (MM-DD-YYYY) AND PLACE MARRIAGE ENDED (City and State or Country)

22A. DATE (MM-DD-YYYY) AND PLACE OF MARRIAGE (City and State or Country)

22B. TO WHOM MARRIED

(First, Middle, Last Name)

22C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

22D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

22E. DATE (MM-DD-YYYY) AND PLACE MARRIAGE ENDED (City and State or Country)

22F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22C, PLEASE EXPLAIN:

23F. WHAT IS YOUR SPOUSE'S ADDRESS? (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

SECTION VI: DEPENDENT CHILDREN (COMPLETE IF YOU HAVE DEPENDENT CHILDREN)

Note - Skip to Section VII if you have no dependent children.

24A. NAME OF DEPENDENT CHILD

(First, Middle initial, Last)

24B. DATE AND PLACE OF BIRTH

(City and State or Country)

24C. SOCIAL SECURITY NUMBER

24A. NAME OF DEPENDENT CHILD

(First, Middle initial, Last)

24B. DATE AND PLACE OF BIRTH

(City and State or Country)

24C. SOCIAL SECURITY NUMBER

24A. NAME OF DEPENDENT CHILD

(First, Middle initial, Last)

24B. DATE AND PLACE OF BIRTH

(City and State or Country)

24C. SOCIAL SECURITY NUMBER

25C. NAME OF PERSON THE CHILD LIVES WITH (If applicable) (First, middle initial, last)

25A. NAME OF DEPENDENT CHILD (First, middle initial, last)

25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)

No. &

Street

25C. NAME OF PERSON THE CHILD LIVES WITH (If applicable) (First, middle initial, last)

SECTION VI: DEPENDENT CHILDREN (COMPLETE IF YOU HAVE DEPENDENT CHILDREN) (CONTINUED)

25A. NAME OF DEPENDENT CHILD (First, middle initial, last)

25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)

25C. NAME OF PERSON THE CHILD LIVES WITH (If applicable) (First, middle initial, last)

SECTION VII: QUESTIONS REGARDING INCOME AND ASSETS (If you need more space, attach a separate sheet.)

26. DO YOU OR YOUR DEPENDENTS RECEIVE SOCIAL SECURITY BENEFITS?