VA Form 21-526EZ

VA Form 21-526EZ | Glasp

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#VA FORM 21-526EZ

Highlights & Notes

- TION INFORMATION (If claim is not an original claim, only Section I, IV (if applicable), V and a signature are required) Page 9 OMB Control No. 2900-0747 Respondent Burden: 25 minutes Expiration Date: 11/30/2025 VA DATE STAMP (DO NOT WRITE IN THIS SPACE) IMPORTANT: Please read the Privacy Act and Respondent Burden on Page 14 before completing the form. Use this form to determine your eligibility for compensation. For more information, you can contact us online through Ask VA: https://ask.va.gov. Ask us a question online or call us toll-free at 1-800-827-1000 (TTY: 711). If you prefer you may complete and submit the form online at www.va.gov. VA forms are available at www.va.gov/vaforms. 2. VETERAN/SERVICEMEMBER'S NAME (First, Middle Initial, Last) 3. SOCIAL SECURITY NUMBER (SSN) 6. DATE OF BIRTH (MM-DD-YYYY) 4. HAVE YOU EVER FILED A CLAIM WITH VA? (If "Yes," provide your file number in Item 5) 5. VA FILE NUMBER 11. EMAIL ADDRESS (Optional) APPLICATION FOR DISABILITY COMPENSATION AND RELATED COMPENSATION BENEFITS 10. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) 13B. NEW ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) 9. TELEPHONE NUMBER (Optional) (Include Area Code) VA FORM NOV 2022 SUPERSEDES VA FORM 21-526EZ, SEP 2019.21-526EZ No. & Street Apt./Unit Number City ZIP Code/Postal CodeState/Province Country No. & Street Apt./Unit Number City ZIP Code/Postal CodeState/Province Country 7. SERVICE NUMBER (If applicable) NOTE: You may either complete the form online or by hand. 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. 8. BDD CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE DUTY (MM-DD-YYYY) 13A. TYPE OF ADDRESS CHANGE (Complete if applicable) (Check only one box) NOTE: If you are temporarily or permanently changing your address, complete Items 13A through 13C. 13C. EFFECTIVE DATE(S) OF NEW ADDRESS (If your change of address is temporary, complete both the beginning and ending date of your temporary address) (If your change of address is permanent, please enter your effective date in the beginning date only) YearDayMonth BEGINNING DATE: ENDING DATE: YearDayMonth 12. IF YOU ARE CURRENTLY A VA EMPLOYEE, CHECK THE BOX (Includes Work Study/Internship) (If you are not a VA employee skip to Section II, if applicable). FDC PROGRAM IDES (Select this option only if you have been referred to the IDES Program by your Military Service Department) BDD Program Claim (Select this option only if you meet the criteria for the BDD Program specified on Instruction Page 5) STANDARD CLAIM PROCESS Enter International Phone Number (If applicable) I agree to receive electronic correspondence from VA in regards to my claim. YES NO TEMPORARY PERMANENT