Dd Form 2860 Test – Fill Out and Use This PDF

APPLICATION FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 1413a, as amended by section 642, P.L. 108-136, November 24, 2003; E.O. 9397, November 1943

(SSN); PDUSD(P&R) Memorandum (May 21, 2003), Subject: Combat-Related Special Compensation (CRSC).

PRINCIPAL PURPOSE(S): Used by career retirees to apply for Combat-Related Special Compensation (CRSC). Application is reviewed to determine eligibility. Information provided by the retiree is used to identify the individual and their service record, determine eligibility for Combat-Related Special Compensation under 10 U.S.C. 1413a, and determine the amount and effective date of payment.

ROUTINE USE(S): Information may be provided to the Department of Veterans Affairs (VA) for these purposes; to the Internal Revenue Service with respect to matters relating to an individual's tax status, and to the Department of Justice or state or local governments when a question of conflicting interest is raised concerning a member's declaration and application for compensation.

DISCLOSURE: Voluntary; however, failure to provide any required information may result in member not being considered eligible for Combat-Related Special Compensation.

COMPLETE THE FORM CAREFULLY AND ACCURATELY.

GENERAL INSTRUCTIONS.

TO HAVE A VALID APPLICATION YOU MUST COMPLETE THE ENTIRE FORM AND SIGN IT IN BLOCK 15 (bottom of Page 5).

Complete and submit this form (pages 1 and 3 need not be included) to apply for Combat-Related Special Compensation (CRSC). Print, type, or use a computer and provide the best information available. If you don't know the answer, enter

"Don't Know" or "DK" - do not leave any item blank.

If you need assistance to complete this form, consult with the agencies that manage your records and information as appropriate, including your branch of service, DFAS, and/or the VA. The following web sites may be helpful also:

Army: http://www.crsc.army.mil/

Navy & Marine Corps: http://www.hq.navy.mil/ncpb/CRSCB/combatrelated.htm

Air Force: http://www.afpc.randolph.af.mil/disability/CRSC/CRSCnew.htm

DoD: http://www.defenselink.mil/prhome/crsc.html

DFAS: http://www.dfas.mil/money/retired/

Coast Guard: http://www.uscg.mil/hq/psc

Sign and date your application. Enclose with your application a clean legible copy of any supporting documents listed on

page 5, items 14a through 14i(6). DO NOT SEND ANY ORIGINAL DOCUMENTS, AS THEY WILL NOT BE RETURNED.

Send your application package to the address listed below for the Uniformed Service from which you retired.

DD FORM 2860 TEST (V3), APR 2004

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 5 Pages

APPLICATION FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

SECTION I - PERSONAL IDENTIFICATION

1. NAME (Last, First, Middle Initial)

2. MAILING ADDRESS AND CONTACT INFORMATION

a. STREET (Include apartment number)

3.a. SOCIAL SECURITY NUMBER

b. SERVICE NUMBER (If different)

4. DATE OF BIRTH (YYYYMMDD)

5. RETIRED RANK/RATE/PAY

b. CITY

c. STATE

d. ZIP CODE+FOUR

GRADE

6.a. UNIFORMED SERVICE FROM

WHICH YOU RETIRED (X only one)

e. DAYTIME TELEPHONE

f. E-MAIL ADDRESS IOptional)

ARMY

NAVY/USMC

USAF

NO. (Include area code)

COAST GUARD

NOAA

PUBLIC HEALTH

b.

OTHER UNIFORMED SERVICE(S) IN WHICH YOU SERVED

c. VA CLAIM, FILE OR C NUMBER

7. DATE RETIRED (YYYYMMDD)

(X all that apply)

ARMY

NAVY/USMC

USAF

COAST GUARD

NOAA

PUBLIC HEALTH

8.a. Are you a Permanent Disability Retiree (PDRL) or are you currently on the

NEITHER

PDRL

TDRL

Temporary Disability Retired List (TDRL) or Neither? (X one)

b. Were you evaluated by a Military Physical Evaluation Board (PEB)?

YES

NO

c. Do you receive Special Monthly Compensation (SMC) from the VA?

YES

NO

d. Does the VA compensate you based on Total Disability because you are classified Individually

YES

NO

Unemployable (IU)?

SECTION II - PRELIMINARY CRSC CRITERIA

NOTE: You must meet ALL criteria of this section or your application will be denied.

9. ANSWER ONLY THE ONE PART THAT APPLIES TO YOUR RETIREMENT:

a. Do you have 20 or more years of service creditable for the computation of the amount of your

YES

NO

retired pay?

OR

b.FOR NON-REGULAR (RESERVE) RETIREMENT ONLY (Retired pay beginning at age 60 based on points under 10 U.S.C. 12731).

(1)	Are you at least 60 years of age?		YES		NO
(2)	Have you received a notice of eligibility for retired pay under Chapter 1223 of Title 10 of the		YES		NO
	United States Code?
(3)	Have you applied for retired pay?		YES		NO
(4)	Do you have 20 qualifying years of service for retirement at age 60?		YES		NO
10. ARE YOU IN A RETIRED STATUS (i.e., are you on the retired rolls, or have you been transferred to the			YES		NO
Fleet Reserve or Fleet Marine Corps Reserve)?
Members recalled to, or retained on, active duty are not in a retired status during the period of such
recall or retention.

If you answered Yes to Items 9, 10, 11, and 12, you appear to meet the Preliminary CRSC Criteria and you should continue to Section III. Otherwise, do not complete the application, but you may apply later if your circumstances change and you meet the Preliminary CRSC Criteria.

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Page 2 of 5 Pages

SECTION III - FINAL CRSC CRITERIA

ORIGIN OF DISABILITIES COMPENSATED BY THE VA

Final CRSC criteria require a combat-related injury or injuries. If you believe you meet the Final CRSC Criteria, you should complete the application. If you do not believe you meet the final criteria, you should not complete the application, but you may apply later if your circumstances change and you believe you meet the Final CRSC Criteria.

In this section list your VA service-connected disabilities you believe to be combat-related and provide information and codes that address the disability and how it was incurred. For each disability there is a four to eight digit number assigned by the VA or by the PEB from the VA Schedule of Rating Disabilities, sometimes called diagnostic codes. The number should be on your VA Rating Decision Code Sheet (or the Findings from the PEB process). This number or numbers should be entered for each diagnosis. There should be ONE diagnosis per box (page 4). Provide supporting documentation to support how each disability was caused. Causation and/or current medical documentation must be included. Objective evidence includes documentation from an outside source such as VA Rating Decisions, and clinical or medical doctor diagnosis with determination of injury/illness and its cause. Include a DD 214, NGB Form 22 (Discharge), 20 year letter, award narratives describing injury, and similar documents to support your claim.

CIRCUMSTANCES UNDER WHICH A DISABILITY IS INCURRED (ORIGIN OF DISABILITY CODES)

PURPLE HEART (PH) - The disability resulted from an injury for which you were awarded the Purple Heart. This should be associated with an incident involving armed conflict. Be sure to include a copy of your Purple Heart award certificate and/or your DD 214 reflecting the award.

DIRECT RESULT OF ARMED CONFLICT (AC) - The disability was incurred in the line of duty as a direct result of armed conflict. The fact that a member incurred the disability during a period of war or an area of armed conflict or while participating in combat operations is not sufficient to support a combat-related determination. There must be a definite causal relationship between the armed conflict and the resulting disability. Armed conflict includes a war, expedition, occupation of an area or territory, battle, skirmish, raid, invasion, rebellion, insurrection, guerrilla action, riot, or any other action in which Service members are engaged with a hostile or belligerent nation, faction, force, or terrorists. Armed conflict may also include such situations as incidents involving a member while interned as a prisoner of war or while detained against his or her will in custody of a hostile or belligerent force or while escaping or attempting to escape from such confinement, prisoner of war, or detained status.

WHILE ENGAGED IN HAZARDOUS SERVICE (HS) - Such service includes, but is not limited to, aerial flight, parachute duty, demolition duty, experimental stress duty, and diving duty. A finding that a disability is the result of such hazardous service requires that the disability be the direct result of actions taken in the performance of such service. Travel to or from such service, or actions incidental to a normal duty status not considered hazardous are not included.

NOTE: Duty aboard a submarine does not, in itself, constitute hazardous service.

IN THE PERFORMANCE OF DUTY UNDER CONDITIONS SIMULATING WAR (SW). - In general this covers disabilities

resulting from simulated combat activity during military training, such as war games, practice alerts, tactical exercises, airborne operations, leadership reaction courses, grenade and live fire weapons practice, bayonet training, hand-to-hand combat training, repelling, and negotiation of combat confidence and obstacle courses. It does not include physical training activities such as calisthenics and jogging or formation running and supervised sports activities. Merely sustaining an injury during military training without participation in combat simulation activity is not considered combat-related.

INSTRUMENTALITY OF WAR (IN) - Incurrence during an actual period of war is not required. However, there must be a direct causal relationship between the instrumentality of war and the disability. The disability must be incurred incident to a hazard or risk of the service. An instrumentality of war is a vehicle, vessel, or device designed primarily for Military Service and intended for use in such Service at the time of the occurrence or injury. It may also include such instrumentalities not designed primarily for Military Service if use of, or occurrence involving, such instrumentality subjects the individual to a hazard peculiar to Military Service. Such use or occurrence differs from the use or occurrence under similar circumstances in civilian pursuits. A determination that a disability is the result of an instrumentality of war may be made if the disability was incurred in any period of service as a result of such diverse causes as wounds caused by a military weapon, accidents involving a military combat vehicle, injury or sickness caused by fumes, gases, or explosion of military ordnance, vehicles, or material. For example, if a member is on a field exercise and is engaged in sporting activity and falls and strikes an armored vehicle, the injury will not be considered to result from the instrumentality of war (armored vehicle) because it was the sporting activity that was the cause of the injury, not the vehicle. On the other hand, if the individual was engaged in the same sporting activity and the armored vehicle struck the member, the injury would be considered the result of an instrumentality of war.

AGENT ORANGE (AO), GULF WAR (GW), RADIATION EXPOSURE (RE), MUSTARD GAS OR LEWISITE (MG) - These codes

should be entered for disabilities awarded by the VA on the basis of presumptions relating to certain disabling conditions described below, even though there is no direct connection and the disability did not occur immediately. You should describe the place, period, and conditions of exposure. These conditions include exposure to Agent Orange, radiation, mustard gas or lewisite, and Gulf War service. Conditions can only be considered under these circumstances if the VA has specifically awarded them as service-connected based on presumptions that include combat-related conditions.

NO OTHER CODE APPLIES (NA) - None of the other codes above describe the circumstances under which this disability was incurred.

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Page 3 of 5 Pages

SECTION III - FINAL CRSC CRITERIA (Continued)

If you are unable to answer any of these questions, enter "Don't Know" or "DK". Complete one Item 13 block for each disability rated by the VA that you think is combat-related. Number your disabilities at the beginning of each Item 13 (for example, 1 of 4, 2 of 4, etc.). If more than two disabilities, use an additional "Page 4," resume numbering in block 13 (for example, 3 of 4, and 4 of 4). Number each page at the bottom accordingly (for example, Page 4-1 of 5 Pages, 4-2 of 5 Pages, etc.).

If using a blank sheet of paper, list your full name and SSN at the top of the page. List each block number and provide information. If unable to answer, list block number with "Don't Know" or "DK".

FOR EACH OF YOUR DISABILITIES RATED BY THE VA THAT YOU THINK IS COMBAT-RELATED, PROVIDE THE FOLLOWING INFORMATION:

13.	DIAGNOSIS		a.(1) VA CODE (DIAGNOSTIC CODE)	a.(2) DIAGNOSIS (Limit to ONE diagnosis for each block. The diagnosis may be
OF			(4 to 8 digit code of VA award)	found on the VA Rating Decision or VA Codesheet or PEB documents.)
b.(1) ORIGINAL VA RATING % AND EFFECTIVE DATE (YYYYMMDD)					b.(2) CURRENT VA RATING % (If different from original) AND
	OF THIS DISABILITY				EFFECTIVE DATE (YYYYMMDD) OF THIS DISABILITY

c.ORIGIN OF DISABILITY CODE (see list below). Mark (X) the ONE code that BEST describes the circumstances under which the disability was incurred. If it applies, use Purple Heart (PH) in preference to any other code.

ORIGIN OF DISABILITY CODES (Full definitions are provided at the beginning of this section on Page 3.)

	PH		HS		IN		GW		MG
	AC		SW		AO		RE		NA - No other code applies
d.	DATE DISABILITY	WAS	INCURRED (YYYYMMDD) e.		WHERE THE DISABILITY WAS INCURRED (Name			of installation or vessel, State or
(Enter year of exposure for AO, GW, RE, and MG)				Region, and Country or Body of Water)

f.MILITARY UNIT TO WHICH YOU WERE ASSIGNED OR ATTACHED WHEN YOU INCURRED THE DISABILITY

g.BRIEFLY DESCRIBE THE SPECIFIC EVENTS/ACTIONS FROM WHICH YOU INCURRED THE DISABILITY. DO NOT SIMPLY DESCRIBE YOUR BILLET. HOW WAS THE DISABILITY CAUSED BY THE COMBAT-RELATED CIRCUMSTANCES YOU ENTERED FOR ITEM c. ABOVE?

h. WHAT SPECIFIC PART(S) OF YOUR ANATOMY WERE AFFECTED WHEN YOU INCURRED THE						i. DO YOU RECEIVE SMC FOR THIS
DISABILITY IN ITEM g. (i.e., right arm, left hand, head, prostate, etc.)?						DISABILITY (X one)?
							YES			NO
COMPLETE ADDITIONAL BLOCKS OF ITEM 13 AS NECESSARY, OR PROCEED TO ITEMS 14 AND 15.
13. DIAGNOSIS			a. (1) VA CODE (DIAGNOSTIC CODE)	a. (2) DIAGNOSIS (Limit to ONE diagnosis for each block. The diagnosis may be
			(4 to 8 digit code of VA award)	found on the VA Rating Decision or VA Codesheet or PEB documents.)
OF
b.(1) ORIGINAL VA RATING % AND EFFECTIVE DATE (YYYYMMDD)					b.(2) CURRENT VA RATING % (If different from original) AND
	OF THIS DISABILITY				EFFECTIVE DATE (YYYYMMDD) OF THIS DISABILITY

c.ORIGIN OF DISABILITY CODE (see list below). Mark (X) the ONE code that BEST describes the circumstances under which the disability was incurred. If it applies, use Purple Heart (PH) in preference to any other code.

ORIGIN OF DISABILITY CODES (Full definitions are provided at the beginning of this section on Page 3.)

	PH		HS		IN		GW		MG
	AC		SW		AO		RE		NA - No other code applies
d.	DATE DISABILITY	WAS	INCURRED (YYYYMMDD) e.		WHERE THE DISABILITY	WAS INCURRED (Name of installation or vessel, State or
(Enter year of exposure for AO, GW, RE, and MG)				Region, and Country or Body of Water)

f.MILITARY UNIT TO WHICH YOU WERE ASSIGNED OR ATTACHED WHEN YOU INCURRED THE DISABILITY

g.BRIEFLY DESCRIBE THE SPECIFIC EVENTS/ACTIONS FROM WHICH YOU INCURRED THE DISABILITY. DO NOT SIMPLY DESCRIBE YOUR BILLET. HOW WAS THE DISABILITY CAUSED BY THE COMBAT-RELATED CIRCUMSTANCES YOU ENTERED FOR ITEM c. ABOVE?

h. WHAT SPECIFIC PART(S) OF YOUR ANATOMY WERE AFFECTED WHEN YOU INCURRED THE	i. DO YOU RECEIVE SMC FOR THIS
DISABILITY IN ITEM g. (i.e., right arm, left hand, head, prostate, etc.)?	DISABILITY (X one)?
		YES				NO
DD FORM 2860 TEST (V3), APR 2004		Page 4 -					of 5 Pages

SECTION IV - DOCUMENTATION SUBMITTED

14.CHECKLIST: Have you included copies of the following documents:

a.Provide copies of DD 214/215 (especially if for retirement and/or your retirement orders) for all periods of military service.

b.Uniformed Service retirement documents and forms; especially any that show combat-related findings made at time of retirement.

c.Purple Heart citation and orders, in addition attach medical documentation (i.e., Clinical Notes, Western Union Telegrams, VA Rating Decisions, etc.) that specifically confirms the injuries/conditions for which you were awarded the Purple Heart.

d.Provide copies of all VA Rating Decisions and code sheets (current and prior). DO NOT REMOVE any pages from these rating decisions.

e.Reserve Retirement and Point Documentation.

f.All PEB disability decisional documents.

g.All VA documents addressing Special Monthly Compensation (SMC) and/or Individual Unemployability (IU).

h.Military/Uniformed Service and VA medical records pertaining to your claimed injuries/conditions.

i.Other Documents (such as assignment orders or award citations showing dates disabilities were incurred and/or treated, and any document describing the circumstances in which the disability was incurred). If you have more than 6 other documents,

list them on a separate sheet of paper and for Item (6) enter "See Additional Sheet".

(1)

(2)

(3)

(4)

(5)

(6)

SECTION V - CERTIFICATION AND WAIVER OF CONCURRENT RETIREMENT AND DISABILITY PAYMENTS (CRDP)

15.COMPLETE THIS SECTION TO ENABLE THE FINANCE CENTER TO MAKE ANY CRSC PAYMENTS YOU QUALIFY TO RECEIVE.

a.I understand that if I am eligible for both Concurrent Retirement and Disability Payments (CRDP) under 10 U.S.C. 1414 and Special Compensation for Certain Combat-Related Disabled Uniformed Service Retirees under 10 U.S.C. 1413a (CRSC), I may not receive both, but must elect which to receive.

NOTE: The Finance Center will make the election to pay you the greater of the two amounts and will notify you and allow you approximately 45 days to change the election if you so desire. You may change this election on an annual basis under procedures provided by DoD.

b.I understand that if my election results in any retroactive payments, any previously paid amounts of CRDP, SCSD, or CRSC for that period of time will be deducted from any amount due for that period.

c.Under penalties of perjury, the information provided above is true to the best of my knowledge and belief and provided with the full knowledge of the penalties for making false statements (18 U.S.C. 287 and 1001 provide for a penalty of not more than $10,000 fine, or 5 years in prison, or both; 31 U.S.C. 3279 provides civil penalties; and 31 U.S.C. 3802 provides administrative penalties).

d.I hereby understand that payments will be deposited to my account of record for Uniformed Services retired pay if I am currently receiving such payments. Otherwise, they will be made to the account of record for my VA disability compensation. After payments begin, I must advise the finance center of any changes to my account.

e. PRINTED NAME (Last, First, Middle Initial)	f. SSN
g. SIGNATURE	h. DATE SIGNED (YYYYMMDD)

DD FORM 2860 TEST (V3), APR 2004

Page 5 of 5 Pages