Veterans Administration Disability Claim Application

First Name

Last Name

Date of Birth

Last 4 numbers of the SSN

Phone Number

Address

City

State

Zip

Dates of Active Duty

Branch of Military

Military Job Title(s)

Were you honorably discharged from the Military?

Yes No

Where were you stationed: (please provide names of all military bases, ships, etc.)

Have you applied for disability benefits with VA?

Yes No

Has your VA disability claim been denied in the past 12 months?

Yes No

Has your previous claim been granted?

Yes No

Did you sustain an injury while in the military?

Yes No

Are you having medical issues you feel are related to your military service?

Yes No

Did you receive medical treatment while in the military?

Yes No

Did you serve outside the United States?

Yes No

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