NABVETS

Honoring the Past and Inspiring the Future

VA Form 21-2680

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1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
6. CLAIMANT'S NAME (First, Middle Initial, Last)
8. RELATIONSHIP OF CLAIMANT TO VETERAN
No. & Street
I agree to receive electronic correspondence from VA in regards to my claim
13. SELECT ONE OF THE FOLLOWING BENEFITS (Choose one)
14A. IS THE CLAIMANT HOSPITALIZED?
ACTUAL LBS.
ESTIMATED LBS
From 9 PM to 9 AM
From 9 AM to 9 PM:
27. DOES THE PATIENT REQUIRE ASSISTANCE WITH ANY OF THE FOLLOWING ACTIVITIES? (Select ALL that apply)
28A. IS THE PATIENT LEGALLY BLIND? (If "Yes," provide explanation)
LEFT EYE
RIGHT EYE
29. DOES THE PATIENT REQUIRE NURSING HOME CARE? (If "Yes," provide explanation)
30. IN YOUR JUDGMENT, DOES THE PATIENT HAVE THE MENTAL CAPACITY TO MANAGE THEIR BENEFIT PAYMENTS, OR ARE THEY ABLE TO DIRECT SOMEONE TO DO SO?
(If "NO," provide the disability(ies) that prevent them from performing this function and any rationale to support your conclusion in the space provided)
37. ARE AIDS SUCH AS CANES, BRACES, CRUTCHES, OR THE ASSISTANCE OF ANOTHER PERSON REQUIRED FOR LOCOMOTION?
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