Va Form 21 526C PDF Details

Are you a veteran or the surviving spouse of a veteran who is considering filing for disability compensation benefits? If so, then one resource you need to know about is VA Form 21 526C. This form confirms an individual’s eligibility and can make the difference in whether their claim is accepted by the Veteran Affairs Department. In this blog post, we'll provide an overview of what VA Form 21 526C encompasses and how it can be used to gain access to veterans disability benefits. Read on for more information!

QuestionAnswer
Form NameVa Form 21 526C
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva form 21 526c, 21 va form 526c, va bdd form, 526c

Form Preview Example

OMB Control No. 2900-0743 Respondent Burden: 15 minutes

PRE-DISCHARGE COMPENSATION CLAIM

(For use only with Benefits Delivery at Discharge (BDD) or Quick Start Claims)

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

THIS FORM WILL BE USED FOR (CHECK ONLY ONE)

 

Benefits Delivery at Discharge (BDD) CLAIMS

Quick Start Claims

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

SECTION I: TO BE COMPLETED BY SERVICE MEMBER

1. SERVICE MEMBER NAME (Last, first, middle)

 

 

 

 

 

 

 

2. PLACE OF SEPARATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. SOCIAL SECURITY NUMBER

 

 

 

4. DATE OF BIRTH (MM,DD,YYYY)

5. SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MALE

 

 

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6A. CURRENT ADDRESS

 

 

 

 

 

 

6B. TELEPHONE NUMBERS (Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

Daytime

 

 

 

 

 

 

 

 

 

 

Street address, rural route, or P.O. Box

 

 

Apt. number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evening

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell phone

 

 

 

 

 

 

City

 

State

 

ZIP Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7A. WORK E-MAIL ADDRESS (If applicable)

 

 

 

 

7B. PERSONAL E-MAIL ADDRESS (If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8A. FORWARDING ADDRESS

 

 

 

 

 

 

 

 

 

 

 

8B. TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

9A. NAME AND RELATIONSHIP OF NEXT

9B. ADDRESS OF NEXT OF KIN

 

 

 

 

9C. TELEPHONE NUMBER

 

 

OF KIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF NEXT OF KIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10A. HAVE YOU EVER FILED A CLAIM WITH VA?

 

 

 

 

 

10B. VA FILE NUMBER

 

 

 

 

 

 

 

YES

 

NO (If "Yes," provide your file number in Item 10B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.WHAT DISABILITIES ARE YOU CLAIMING? SUBMIT ADDITIONAL SUPPORTING STATEMENTS AND INFORMATION CONCERNING YOUR CLAIMED DISABILITIES ON VA FORM 21-4138, STATEMENT IN SUPPORT OF CLAIM, AVAILABLE AT www.va.gov/vaforms

IMPORTANT: If claiming dependents, please attach a completed VA Form 21-686c, Declaration of Status of Dependents, available at www.va.gov/vaforms

SECTION II: SERVICE INFORMATION

12A. DID YOU SERVE UNDER ANOTHER NAME?

YES (If "Yes," go to Item 12B)

NO (If "No," go to Item 13A)

12B. PLEASE LIST OTHER NAME(S) YOU SERVED UNDER

13A. I ENTERED THIS CURRENT PERIOD OF

 

13B. BRANCH OF SERVICE

13C. ANTICIPATED DATE

13D. DID YOU SERVE IN A

 

ACTIVE SERVICE ON (MM,DD,YYYY)

 

 

 

OF RELEASE FROM

 

COMBAT ZONE SINCE

 

 

 

 

 

 

 

 

 

ACTIVE DUTY

9-11-2001?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

mo

day yr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE

 

14B. DATE OF ACTIVATION (MM,DD,YYYY)

 

AUTHORITY OF TITLE 10, U.S.C.?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

(If "Yes," provide date of activation in Item 14B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo day

yr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?

15B. WHAT IS THE TELEPHONE NUMBER OF YOUR CURRENT UNIT? (Include Area Code)

16A. DO YOU HAVE ADDITIONAL PERIODS OF ACTIVE SERVICE?

YES (If "Yes," go to Item 16B)

NO (If "No," go to Item 17A)

16B. I PREVIOUSLY ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)

mo day yr

VA FORM

21-526c

JUL 2009

 

SECTION III: MILITARY RETIRED PAY

17A. WILL YOU RECEIVE RETIRED PAY?

 

17B. TYPE OF RETIRED PAY?

 

 

 

 

 

 

 

 

 

LONGEVITY

 

 

DISABILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

(If "Yes," complete Item 17B)

 

 

 

TDRL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18A. WILL YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE PAY?

18B. LIST AMOUNT (If known)

18C. LIST TYPE (If known)

 

 

YES

 

NO

(If "Yes," complete Items 18B and 18C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT: Unless you check the box in Item 19 below, you are telling us that you are choosing to receive VA compensation instead of military retired pay, if it is determined you are entitled to both benefits. If you are awarded military retired pay prior to compensation, we will reduce your retired pay by that amount. VA will notify the Military Retired Pay Center of all benefit changes.

If you receive both military retired pay and VA compensation, some of the amount you get may be recouped by VA, or, in the case of Voluntary Separation Incentive (VSI), by the Department of Defense.

19. No, I do not want VA compensation in lieu of military retired pay.

SECTION IV: DIRECT DEPOSIT INFORMATION

Generally, all Federal payments are required to 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 20, 21 and 22 to enroll in Direct Deposit. If you do not have a bank account, we will give you a waiver from Direct Deposit, just check the box below in Item 20. The Treasury Department is working to make bank accounts available in such situations. Once these accounts are available, you will be able to decide whether you wish to sign-up for one of the accounts or continue to receive a paper check. You can also request a waiver if you have other circumstances that you feel would cause a hardship if you enrolled in Direct Deposit. You can write to: Department of Veterans Affairs, 125 S. Main Street, Suite B, Muskogee, OK 74401-7004, and give us a brief description of why you do not wish to participate in Direct Deposit.

20.ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)

 

 

 

 

 

 

 

 

 

 

 

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT

 

 

CHECKING

 

 

SAVINGS

 

 

 

WITH A FINANCIAL INSTITUTION OR CERTIFIED

 

 

 

 

 

 

 

 

 

 

 

PAYMENT AGENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. NAME OF FINANCIAL INSTITUTION (Please provide the name of

22. ROUTING OR TRANSIT NUMBER (The first nine numbers located

 

the bank where you want your direct deposit)

 

 

 

 

at the bottom left of your check)

 

 

 

 

 

 

 

 

 

 

 

 

SECTION V: CERTIFICATIONS 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 except protected health information, and I waive any privilege which makes the information confidential.

23A. YOUR SIGNATURE (Do NOT print)

23B. DATE SIGNED

SECTION VI: WITNESSES TO SIGNATURE

24A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

24B. PRINTED NAME AND ADDRESS OF WITNESS

25A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

25B. PRINTED NAME AND ADDRESS OF WITNESS

PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The responses you submit are considered confidential (38 U.S.C. 5701). 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 necessary to determine maximum benefits under the law. Information submitted is subject 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 the 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. 5101(c)(1). 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 15 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 www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-526c, JUL 2009

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This PDF will need particular info to be typed in, hence you should take the time to type in what's expected:

1. It is very important complete the va bdd form accurately, thus pay close attention when filling in the segments including all of these blank fields:

Tips on how to prepare va 526c form 21 stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - IMPORTANT If claiming dependents, A DID YOU SERVE UNDER ANOTHER NAME, B PLEASE LIST OTHER NAMES YOU, SECTION II SERVICE INFORMATION, YES, If Yes go to Item B, If No go to Item A, A I ENTERED THIS CURRENT PERIOD OF, B BRANCH OF SERVICE, ACTIVE SERVICE ON MMDDYYYY, C ANTICIPATED DATE OF RELEASE FROM, D DID YOU SERVE IN A, COMBAT ZONE SINCE, mo day yr, and YES with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

va 526c form 21 conclusion process detailed (step 2)

3. This subsequent part is normally quite uncomplicated, A WHAT IS THE NAME AND ADDRESS OF, B WHAT IS THE TELEPHONE, NUMBER OF YOUR CURRENT UNIT, A DO YOU HAVE ADDITIONAL PERIODS, B I PREVIOUSLY ENTERED ACTIVE, YES, If Yes go to Item B, NO If No go to Item A, VA FORM, JUL c, and mo day yr - all these empty fields will have to be filled in here.

va 526c form 21 completion process explained (stage 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - A WILL YOU RECEIVE RETIRED PAY, YES, If Yes complete Item B, B TYPE OF RETIRED PAY, LONGEVITY, DISABILITY, TDRL, SECTION III MILITARY RETIRED PAY, A WILL YOU RECEIVE ANY TYPE OF, B LIST AMOUNT If known, C LIST TYPE If known, YES, If Yes complete Items B and C, IMPORTANT Unless you check the box, and If you receive both military - to proceed further in your process!

How you can complete va 526c form 21 stage 4

5. This document should be finalized by going through this part. Further there can be found an extensive listing of fields that require accurate details for your document submission to be accomplished: the bank where you want your, at the bottom left of your check, SECTION V CERTIFICATIONS AND, I certify and authorize the, B DATE SIGNED, A SIGNATURE OF WITNESS If claimant, B PRINTED NAME AND ADDRESS OF, SECTION VI WITNESSES TO SIGNATURE, A SIGNATURE OF WITNESS If claimant, B PRINTED NAME AND ADDRESS OF, and PRIVACY ACT NOTICE The form will.

SECTION VI WITNESSES TO SIGNATURE, at the bottom left of your check, and SECTION V CERTIFICATIONS AND in va 526c form 21

Regarding SECTION VI WITNESSES TO SIGNATURE and at the bottom left of your check, be certain you get them right in this current part. Those two are surely the key fields in this form.

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