Form DA-5425 is a Department of Veterans Affairs (VA) form that is used to apply for disability compensation. This form can be used to apply for both service-related and nonservice-related disabilities. The VA will use the information provided on this form to determine if you are eligible for disability benefits and, if so, the amount of benefits you will receive. It is important to complete the Form DA-5425 accurately and truthfully, as providing inaccurate information could result in your claim being denied. In this blog post, we will provide a detailed overview of Form DA-5425 and explain how to complete it correctly. We hope this information will help you file a successful disability compensation claim with the VA.
| Question | Answer |
|---|---|
| Form Name | Form Da 5425 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | da 31, dgp da 12 formato pdf, da 5425 r, form 5425 |
APPLICANT/NOMINEE PERSONAL FINANCIAL STATEMENT
For use of this form, see AR
AUTHORITY:
PRINCIPAL PURPOSES:
ROUTINE USES:
DISCLOSURE:
PRIVACY ACT STATEMENT
5 U.S.C. 301, Departmental Regulation; 10 U.S.C. 3013, Secretary of the Army; AR
To verify that the individual meets financial criteria and is suitable for selection and assignment for recruiting duty. This form will be used during inprocessing at the Army Recruiter Course to confirm continued eligibility
None. The "Blanket Routine Uses" set forth at the beginning of the Army's Compilations of System of Records Notices apply to this system.
Voluntary. However, failure to provide the requested information may result in selection and assignment made without consideration of your financial status.
1.NAME (Last, First, Middle)
2. GRADE
3. Are you now or have you ever filed for bankruptcy? |
(If yes, state when, where, and why.) |
YES |
NO |
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4. |
Have you ever received a letter(s) of indebtedness? (If yes, enter month and year below.) |
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MONTH |
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YEAR |
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MONTH |
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YEAR |
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5. |
MONTHLY INCOME |
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AMOUNT |
TOTAL |
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a. Basic Pay |
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b. Separate Rations |
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c. Clothing Allowance |
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d. Total Military Income Before Taxes (Total of a thru c above) |
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e. Subtract FICA and Income Taxes |
(Subject) |
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f. Total After Tax Income |
(Equal) |
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g. Any other Monthly Income (Do not include Spouse's income) |
(Add) |
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TOTAL MONTHLY SPENDABLE INCOME |
(Equal) |
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ADDITIONAL INFORMATION OR REMARKS |
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DA FORM 5425, SEP 2010 |
PREVIOUS EDITIONS ARE OBSOLETE. |
Page 1 of 3 |
APD PE v1.00ES
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6. ASSETS |
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YES |
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AMOUNT |
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a. Do you have a savings account? (Enter approximate balance) |
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b. Do you own stocks, bonds, or benefit from a trust? (Enter approximate value) |
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c. Do you own (with no payments): |
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(1) |
Vehicles |
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MAKE |
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MODEL |
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YEAR |
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(Enter total estimated value) |
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(2) |
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Home |
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Trailer |
("x" one) |
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(Enter total estimated value) |
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(3) |
Furniture (Enter estimated value) |
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(4) |
Land (Enter estimated value) |
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TOTAL ASSETS |
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7. MONTHLY EXPENDITURES/LIABILITIES |
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MONTHLY PAYMENT |
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a. Cost of food (Include meals eaten out, school lunches, etc.) |
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b. Clothing (Dry cleaning/laundry) |
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c. Medical (Doctor, orthodontist, special medications, special schooling or treatment for handicapped |
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family member) |
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d. Insurance (Life, auto, homeowner, other) |
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e. Vehicle expenses |
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(1) |
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MAKE |
MODEL |
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YEAR |
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(Enter total estimated value) |
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(2) |
Gas, Oil, maintenance |
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f. List charge cards or credit cards for which you have an outstanding balance: |
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BALANCE OWED |
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NAME |
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DA FORM 5425, SEP 2010 |
Page 2 of 3 |
APD PE v1.00ES
7. MONTHLY EXPENDITURES/LIABILITIES (Continued) |
BALANCE OWED |
MONTHLY PAYMENT |
g.List finance companies, banks, credit unions, or other institutions where you have an outstanding loan:
NAME
h. Alimony or child support.
i.Any allotments for purposes not listed above?
(If yes, state for what purpose.)
YES
NO
j. Any other indebtedness or financial obligation not listed above? (Use
remarks section to explain if necessary.)
TOTAL MONTHLY EXPENDITURES/LIABILITIES
REMARKS
8. SIGNATURE OF VOLUNTEER/NOMINEE
DA FORM 5425, SEP 2010
9. DATE
Page 3 of 3
APD PE v1.00ES