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Veterans Administration Disability Claim Application Form
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Dates of Active Duty
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Were you honorably discharged from the Military?
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Where were you stationed: (please provide names of all military bases, ships, etc.)
Have you applied for disability benefits with VA?
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Has your VA disability claim been denied in the past 12 months?
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Has your previous claim been granted?
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What percent rate?
Did you sustain an injury while in the military?
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No
What was the injury you sustained and when did it occur?
Are you having medical issues you feel are related to your military service?
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Please describe service related medical issues and estimated diagnosis dates
Did you receive medical treatment while in the military?
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When and where were you treated?
Did you serve outside the United States?
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Where?
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