Veterans Administration Disability Claim Application Form

Last 4 numbers of the SSN

Dates of Active Duty

Military Job Title(s)

Where were you stationed? (please provide names of all military bases, ships, and the period when you were stationed there)

Were you honorably discharged from the Military?

Yes No

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

Did you ever smoked tobacco products?

Yes No

Have you ever been represented by an attorney for a VA appeal before?

Yes No

Do you have anyone else to add as a contact for your Case Review?

Yes No

Do you have a diagnosis for all conditions to appeal?

Yes No

Have you ever been diagnosed with any type of cancer at any point during your life?

Yes No

Do you currently have a rating with VA?

Yes No

Have you ever filed for the PACT Act before?

Yes No

Message (max 300 characters)

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I declare under penalty of perjury that all information provided on this form is true and correct to the best of my knowledge.

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