VBA VA Form 21-526EZ

Your claim will be processed as described on pages 1 through 8 unless one of the following special programs is selected.

If you submit additional information or evidence after you submit your "fully developed" claim, then VA will remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard Claim Process.

Select IDES only if you have been referred to the IDES Program by your Military Service Department.

Select BDD Program Claim only if you meet the criteria for the BDD Program specified on Instruction Page 5.

Under the Benefits Delivery at Discharge (BDD) program you can submit a disability claim 90 to 180 days prior to your anticipated separation date from active duty.

If the claim is not an original claim, only Section I, IV (if applicable), V and a signature are required.

If completed by hand, print the information requested in ink, neatly, and legibly, insert one letter per box, and completely fill in each applicable check box to help expedite processing of the form.

Enter the Veteran/Servicemember's name in box 2: First name, Middle Initial, Last name.

Enter your Social Security Number (SSN) in box 3.

Enter your date of birth in box 6 as MM-DD-YYYY.

Box 7, Service Number/DOD ID Number, is for use if applicable.

Box 8 is for BDD claims only: provide the date or anticipated date of release from active duty (MM-DD-YYYY).

Have you ever filed a claim with VA? If "Yes," provide your file number in Item 5.

Box 9, Telephone Number, is optional: include the area code.

Box 10: enter your current mailing address (number and street or rural route, P.O. Box, City, State, ZIP Code and Country).

Box 11, Email Address, is optional. Check the box if you agree to receive electronic correspondence from VA in regards to your claim.

15A. Are you claiming any conditions related to toxic exposures? If "Yes," complete Items 15B, 15C, 15D and 15E. If "No," skip to Item 16, Section V: Claim Information.

15D. Have you been exposed to any of the following? (Check all that apply) Asbestos; mustard gas; radiation; military occupational specialty (MOS)-related toxin; SHAD (Shipboard Hazard and Defense); contaminated water at Camp Lejeune; other (specify).

Box 16: list the current disability(ies) or symptoms that you claim are related to your military service and/or service-connected disability. If applicable, identify whether a disability is due to a service-connected disability; confinement as a prisoner of war; exposure to Agent Orange, asbestos, mustard gas, ionizing radiation, or Gulf War environmental hazards; or a disability for which compensation is payable under 38 U.S.C. 1151.

For each disability, if due to exposure, event, or injury, please specify (e.g., Agent Orange, radiation, burn pits), enter the approximate date the disability(ies) began or worsened, and explain how the disability(ies) relates to the in-service event/exposure/injury.

Box 17: list VA medical center(s) (VAMC) and Department of Defense (DOD) military treatment facilities (MTF) where you received treatment after discharge for your claimed disability(ies) listed in Item 16 and provide approximate beginning date (month and year) of treatment. If additional space is needed attach a separate sheet and include your name, Social Security Number and item number.

If treatment began from 2005 to present, you do not need to provide dates in Item 17B.

18A. Did you serve under another name? If "Yes," complete Item 18B: list the other name(s) you served under. If "No," skip to Item 19A.

20A. Most Recent Active Service Dates: enter the entry date and exit date as month, day and year. 20B. Place of Last or Anticipated Separation.

21A. Are you currently serving or have you ever served in the Reserves or National Guard? If "Yes," complete Items 21B through 21F. If "No," skip to Item 22A.

24A. Are you receiving military retired pay? If "Yes," complete Items 24C and 24D. 24B. Will you receive military retired pay in the future? If "Yes," explain (e.g. future Reserve/National Guard retirement, pending MEB/PEB and also complete Items 24C and 24D).

Submission of this application constitutes a waiver of military retired pay in an amount equal to VA compensation awarded, if you are entitled to both benefits.

29. Check the box to certify that you do not have an account with a financial institution or certified payment agent. (If you check this box skip to Section IX)

30. Account Number: check only one box, Checking or Savings, and provide the account number. 31. Name of Financial Institution: provide the name of the bank where you want your direct deposit. 32. Routing or Transit Number: the first nine numbers located at the bottom left of your check.

By signing you certify and authorize the release of information, and you certify that the statements in this document are true and complete to the best of your knowledge.

By signing you certify you have enclosed all the information or evidence that will support your claim, to include an identification of relevant records available at a Federal facility such as a VA medical center; OR, you have no information or evidence to give VA to support your claim; OR, you have checked the box in Item 1, on page 9, indicating you want your claim processed under the standard claim process because you plan to submit additional evidence in support of your claim.

34A and 35A, Signature of Witness: only sign if the veteran signed in 33A using an "X". 34B and 35B: printed name and address of witness.

Section XI is required only if Item 33A is blank.

If you disagree with an evaluation decided within the past year and have new and relevant evidence, or if you are filing a supplemental claim (a claim after an initial claim for the same or similar benefit was previously decided) and have new and relevant evidence, please complete and submit VA Form 20-0995, Decision Review Request: Supplemental Claim.

Sign in 33A: Veteran/Service Member signature (required). Enter the date signed (MM-DD-YYYY) in 33B.

You have up to one year from the date VA receives the claim to submit the information and evidence necessary to support your claim.

Mail to Department of Veterans Affairs Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444.

The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.