Fillable Form VA 21-526EZ
VA 21-526EZ Form is used by a retired or disabled veteran who wishes to receive benefits. The document will request for personal information of the veteran to ensure that the proper benefits are handed to them.
What is Form VA 21-526EZ?
Officially Application for Disability Compensation and Related Compensation Benefits, Form VA 21-526EZ is a Department of Veteran Affairs (VA) form that veterans use to submit a claim for disability compensation and related compensation benefits.
Filing Form VA 21-526EZ starts the application to get benefits from the VA. Before completing the form, a veteran must know if he or she meets the set qualifications in order to receive VA benefits. Form VA 21-526EZ asks the applicant to describe relevant information and submit evidence to qualify.
In general, a veteran may qualify for disability benefits if he or she was diagnosed with a service-connected medical condition or disability. However, if a veteran received an other than honorable, bad conduct, or dishonorable discharge, he or she may not be eligible for VA disability benefits.
There are two claim options when filing Form VA 21-526EZ:
How to submit Form VA 21-526EZ?
You may Form VA 21-526EZ in three methods:
By Mail
Department of Veterans Affair
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
Via Fax
844-531-7818 (Toll-Free)
248-524-4260 (For Foreign Claims)
Online
Go to the official site of the Department of Veteran Affairs
How to Fill Out Form VA 21-526EZ?
Item 1
Select the type of claim program or process. You can choose:
Section I: Identification and Claim Information
Item 2
Provide your full veteran or service member name.
Item 3
Provide your social security number (SSN).
Item 4
Select “Yes” if you have ever filed a claim with VA and “No” if otherwise.
Item 5
If Number 4 is yes, provide VA File Number.
Item 6
Provide your date of birth.
Item 7
Provide your veteran service number, if applicable.
Item 8
Select “Male” or “Female.”
Item 9
For BDD Claims only. Provide the date or anticipated date of release from active duty in MM-DD-YYYY format.
Item 10
Provide telephone numbers, including area code.
Item 11
Provide your current mailing address.
Item 12
Provide email address, if available.
Item 13
Check the box if you are currently a VA employee.
Section II: Change of Address
Complete Items 14A through 14C if you are temporarily or permanently changing your address.
Item 14A
Determine the type of address change, either “Temporary” or “Permanent.”
Item 14B
Provide the complete new address.
Item 14C
Provide the effective dates of the new address.
Section III: Homeless information
Complete this section only if you are homeless or at risk of becoming homeless.
Item 15A
Select “Yes” if you are currently homeless. “No” if not.
Item 15B
Mark the box that applies to your living situation:
Item 15C
Select “yes” if you are currently at risk of becoming homeless. “No” if not.
Item 15D
Mark the box that applies to your living situation:
Item 15E
Provide the name of the person VA can contact to reach you.
Item 15F
Provide the telephone number of the person VA can contact to reach you.
Section IV: Claim Information
Item 16
List current disabilities or symptoms that you claim are military service-related. Provide exposure type, how the disabilities relate to the in-service event, exposure, or injury, and approximate date the disabilities began or worsened.
Item 17
List VA Medical Centers (VAMC) and Department of Defense (DOD) Military Treatment Facilities (MTF) where you received treatment for your claimed disabilities in Item 16. Provide the approximate beginning dates of treatment.
Section V: Service Information
Item 18A
Select “Yes” if you served under another name. “No” if not.
Item 18B
List the other names you served under if you answered Item 18A yes.
Item 19A
Select branch of service:
Item 19B
Select component:
Item 20A
Provide the most recent active service dates in MM-DD-YYYY format.
Item 20B
Provide the place of last or anticipated separation.
Item 20C
Select “Yes” is you served in a combat zone since 9-11-2001. “No” if not.
Item 20D
Provide additional periods of service.
Item 21A
Select “Yes” if you are currently serving or have ever served in the reserves or national guard. “No” if not. If yes, answer Items 21B to 21F; if no, skip to Item 22A.
Item 21B
Select component:
Item 21C
Provide dates of obligation.
Item 21D
Provide current or last assigned name and address of unit.
Item 21E
Provide current or assigned phone number of unit.
Item 21F
Select “Yes” if you are currently receiving inactive duty training pay. “No” if not.
Item 22A
Select “Yes” if currently activated on federal orders within the national guard or reserves. “No” if not. If yes, complete Items 22B and 22C.
Item 22B
Provide date of activation in MM-DD-YYYY format.
Item 22C
Provide anticipated separation date in MM-DD-YYYY format.
Item 23A
Select “Yes” if you have ever been a prisoner of war. “No” if not. If yes, complete Item 23B.
Item 23B
Provide dates of confinement.
Section VI: Service Pay
Item 24A
Select “Yes” if you are receiving military retired pay. “No” if not. If yes, complete Items 24C and 24D.
Item 24B
Select “Yes” if you will receive military retired pay in the future. “No” if not. If yes, explain in the space provided.
Item 24C
Select the branch of service:
Item 24D
Provide the monthly amount.
Item 25
Provide retired status:
Item 26
Mark the box if you do not want to be paid VA compensation. If you are currently in receipt of VA compensation and you check the box in Item 26, your VA compensation will be terminated, if you are also eligible for military retired pay.
Item 27A
Select “Yes” if you ever received separation pay, disability severance pay, or any other lump-sum payment from your branch of service. “No” if not. If yes, complete Items 27B to 27D.
Item 27B
Provide the date the payment was received in MM-DD-YYYY format.
Item 27C
Provide the branch of service:
Item 27D
Provide the pre-tax amount received.
Item 28
Mark the box if you do not want to receive VA compensation.
Section VII: Direct Deposit Information
Item 29
Mark 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 VIII.
Item 30
Provide the account number. Select if checking or savings account.
Item 31
Provide the name of the financial institution.
Item 32
Provide the routing or transit number.
Section VIII: Claim Certification and Signature
Item 33A
Provide your signature.
Item 33B
Provide the date when you signed Form VA 21-526EZ.
Section IX: Witnesses to Signature
Items 34A, 34B, 35A, 35B
Provide signatures, names, and addresses of witnesses. Only use this section if the veteran signed in Item 33A using an “X.”
Section X: Alternate Signer Certification and Signature
Only use this section if Item 33A is blank.
Item 36A
Provide the signature of the alternate signer.
Item 36B
Provide the date when Form VA 21-526EZ was signed by the alternate signer.
Section XI: Power of Attorney (POA) Signature
A POA cannot sign for an original claim only.
Item 37A
Provide the signature of the POA.
Item 37B
Provide the date when Form VA 21-526EZ was signed by the POA.