VA Form 21-526EZ

Please enable JavaScript in your browser to complete this form.

1. SELECT THE TYPE OF CLAIM PROGRAM/PROCESS THAT APPLIES TO YOU. NOTE: Your claim will be processed as described on pages 1 through 8 unless one of the following special programs is selected. See Instruction pages 1 through 3 for definitions of the Fully Developed Claim (FDC) Program (Optional Expedited Process) or the Standard Claim Process.

FDC PROGRAM
STANDARD CLAIM PROCESS
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)

2. VETERAN/SERVICEMEMBER'S NAME (First, Middle Initial, Last)

First

Middle

Last

3. SOCIAL SECURITY NUMBER (SSN)

4. HAVE YOU EVER FILED A CLAIM WITH VA?

(If "Yes," provide your file number in Item 5)

5. VA FILE NUMBER

7. SERVICE NUMBER (If applicable)

8. BDD CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE DUTY (MM-DD-YYYY)

9. TELEPHONE NUMBER (Optional) (Include Area Code)

Enter International Phone Number (If applicable)

10. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

11. EMAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

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).

Select

13A. TYPE OF ADDRESS CHANGE (Complete if applicable)

TEMPORARY
PERMANENT

13B. NEW ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

VETERAN'S SOCIAL SECURITY NO.

14A. ARE YOU CURRENTLY HOMELESS?

YES (If "Yes," complete Item 14B regarding your living situation)
NO

14B. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:

LIVING IN A HOMELESS SHELTER
NOT CURRENTLY IN A SHELTERED ENVIRONMENT (e.g., living in a car or tent)
STAYING WITH ANOTHER PERSON
FLEEING CURRENT RESIDENCE

OTHER (Specify)

14C. ARE YOU CURRENTLY AT RISK OF BECOMING HOMELESS?

YES (If "Yes," complete Item 14D regarding your living situation)
NO

14D. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:

HOUSING WILL BE LOST IN 30 DAYS
LEAVING PUBLICLY FUNDED SYSTEM OF CARE (e.g., homeless shelter)

OTHER (Specify)

14E. POINT OF CONTACT (Name of person VA can contact in order to get in touch with you)

14F. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

15A. ARE YOU CLAIMING ANY CONDITIONS RELATED TO TOXIC EXPOSURES? NOTE: See Page 4 of the Instructions for further information on the evidence needed to support your claim for presumptive service connection. (You can also refer to the following websites for more information: PACT ACT (https://www.va.gov/PACT) and PUBLIC HEALTH MILITARY EXPOSURES (https://www.publichealth.va.gov/exposures/index.asp))

YES (If "Yes," complete Items 15B, 15C, 15D and 15E)
NO (If "No," skip to Item 16, Section V: Claim Information)

15B. DID YOU SERVE IN ANY OF THE FOLLOWING GULF WAR HAZARD LOCATIONS? Iraq; Kuwait; Saudi Arabia; the neutral zone between Iraq and Saudi Arabia; Bahrain; Qatar; the United Arab Emirates; Oman; Yemen; Lebanon; Somalia; Afghanistan; Israel; Egypt; Turkey; Syria; Jordan; Djibouti; Uzbekistan; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; and the Red Sea

FROM:

TO:

15C. DID YOU SERVE IN ANY OF THE FOLLOWING HERBICIDE (e.g., Agent Orange) LOCATIONS? Republic of Vietnam to include the 12 nautical mile territorial waters; Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham Province; Guam or American Samoa; or in the territorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarized zone; aboard (to include repeated operations and maintenance with) a C-123 aircraft known to have been used to spray an herbicide agent (during service in the Air Force and Air Force Reserves).

Please list other location(s) where you served, if not listed above:

FROM:

TO:

15D. HAVE YOU BEEN EXPOSED TO ANY OF THE FOLLOWING? (Check all that apply)

OTHER (Specify)

FROM:

TO:

15E. IF YOU WERE EXPOSED MULTIPLE TIMES, PLEASE PROVIDE ALL ADDITIONAL DATES AND LOCATIONS OF POTENTIAL EXPOSURE

VETERAN'S SOCIAL SECURITY NO.

A. ENTER THE DISABILITY TREATED AND NAME/LOCATION OF THE TREATMENT FACILITY

C. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT

Don't have date
Don't have date
Don't have date

VETERAN'S SOCIAL SECURITY NO

18A. DID YOU SERVE UNDER ANOTHER NAME?

YES (If "Yes," complete Item 18B)
NO (If "No," skip to Item 19A)

18B. LIST THE OTHER NAME(S) YOU SERVED UNDER

19B. COMPONENT

ACTIVE
RESERVES
NATIONAL GUARD

20B. PLACE OF LAST OR ANTICIPATED SEPARATION

20C. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001?

20D. ADDITIONAL PERIODS OF SERVICE (Indicate enlistment and discharge date(s), if applicable)

21A. ARE YOU CURRENTLY SERVING OR HAVE YOU EVER SERVED IN THE RESERVES OR NATIONAL GUARD?

YES (If "Yes," complete Items 21B through 21F)
NO (If "No," skip to Item 22A)

21B. COMPONENT

NATIONAL GUARD
RESERVES

21D. CURRENT OR LAST ASSIGNED NAME AND ADDRESS OF UNIT:

21E. CURRENT OR ASSIGNED PHONE NUMBER OF UNIT (Include Area Code)

21F. ARE YOU CURRENTLY RECEIVING INACTIVE DUTY TRAINING PAY?

22A. ARE YOU CURRENTLY ACTIVATED ON FEDERAL ORDERS WITHIN THE NATIONAL GUARD OR RESERVES?

YES (If "Yes," complete Items 22B & 22C)
NO

23A. HAVE YOU EVER BEEN A PRISONER OF WAR?

YES (If "Yes," complete Item 23B)
NO

24A. ARE YOU RECEIVING MILITARY RETIRED PAY?

YES (If "Yes," complete Items 24C and 24D)
NO

24B. WILL YOU RECEIVE MILITARY RETIRED PAY IN THE FUTURE?

YES (If "Yes," explain below (e.g. future Reserve/National Guard retirement, pending MEB/PEB and also complete Items 24C and 24D)
NO

24D. MONTHLY AMOUNT

25. RETIRED STATUS

RETIRED
PERMANENT DISABILITY RETIRED LIST
TEMPORARY DISABILITY RETIRED LIST

IMPORTANT: VA COMPENSATION PAY IS NON-TAXABLE. THEREFORE, VA COMPENSATION PAY MAY BE THE GREATER BENEFIT

26. Do NOT pay me VA compensation. I do NOT want to receive VA compensation in lieu of retired pay.

VETERAN'S SOCIAL SECURITY NO

27A. HAVE YOU EVER RECEIVED SEPARATION PAY, DISABILITY SEVERANCE PAY, OR ANY OTHER LUMP SUM PAYMENT FROM YOUR BRANCH OF SERVICE?

YES (If "Yes," complete Items 27B through 27D)
NO

27D. AMOUNT RECEIVED (Provide pre-tax amount)

IMPORTANT: VA COMPENSATION PAY IS NON-TAXABLE. THEREFORE VA COMPENSATION PAY MAY BE THE GREATER BENEFIT.

28. Do NOT pay me VA compensation. I do NOT want to receive VA compensation in lieu of training pay.

29. I CERTIFY THAT I 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 below and provide the account number) Account No.:

31. NAME OF FINANCIAL INSTITUTION (Provide the name of the bank where you want your direct deposit)

Select account

CHECKING
SAVINGS

32. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the bottom left of your check)

34B. PRINTED NAME AND ADDRESS OF WITNESS

35B. PRINTED NAME AND ADDRESS OF WITNESS

VETERAN'S SOCIAL SECURITY NO.

36B. DATE SIGNED (MM-DD-YYYY)

37B. DATE SIGNED (MM-DD-YYYY)

VETERAN'S SOCIAL SECURITY NO

CURRENT DISABILITY(IES)

IF DUE TO EXPOSURE, EVENT, OR INJURY, PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits)

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY

APPROXIMATE DATE DISABILITY(IES) BEGAN OR WORSENED