LexisNexis® Automated Veterans Benefits Forms

Veterans’ Benefits Forms

Foreword by Ronald Abrams, National Veterans Legal Services Program
Veterans Benefits Manual Advocacy Checklist for Different Types of VA Claims (App17-A) (Word)
Veterans Benefits Manual Advocacy Checklist for Different Types of VA Claims (App17-A) (WordPerfect)

VA Compensation and Pension Forms

Veteran’s Supplemental Claim (21-256b)
Application for Annual Clothing Allowance (Under 38 U.S.C. 1162) (10-8678)
Application for Annual Clothing Allowance (Under 38 U.S.C. 1162) (10-8678) (Instructions)
Application for Automobile or Other Conveyance and Adaptive Equipment (21-4502)
Application for Automobile or Other Conveyance and Adaptive Equipment (21-4502) (Instructions)
Application for Benefits for Certain Children with Disabilities Born of Vietnam Veterans (21-0304)
Application for Ben. for Certain Children with Disab. Born of Vietnam Vets. (21-0304) (Instructions)
Application for Burial Benefits (Under 38 U.S.C. Chapter 23) (21-530)
Application for Burial Benefits (Under 38 U.S.C. Chapter 23) (21-530) (Instructions)
Application for Dependency and Indemnity Compensation (21-534)
Application for Dependency and Indemnity Compensation (21-534) (Instructions)
Application for Dependency and Indemnity Compensation by a Surviving Spouse or Child (21-534a)
Application for Dependency and Indemnity Compensation by a Surviving Spouse or Child (Instructions)
Application for Dependency and Indemnity Compensation by Parent(s) (21-535)
Application for Dependency and Indemnity Compensation by Parent(s) (21-535) (Instructions)
Application for Exclusion of Children’s Income (21-0571)
Application for Reimbursement from Accrued Amounts Due a Deceased Beneficiary (21-601)
Application for Reimbursement from Accrued Amounts Due a Deceased Beneficiary (21-601) (Inst.)
Application for United States Flag for Burial Purposes (21-2008)
Application for United States Flag for Burial Purposes (21-2008) (Instructions)
Declaration of Status of Dependents (21-686c)
Election of Comp in Lieu of Retired Pay or Waiver of Retirement Pay to Secure Comp from VA (21-651)
Eligibility Verification Report (21-0510) (Instructions)
Improved Pension Eligibility Verification Report (Child or Children) (21-0519c-1)
Improved Pension Eligibility Verification Report (Surviving Spouse with Children) (21-0519s-1)
Improved Pension Eligibility Verification Report (Surviving Spouse with No Children) (21-0518-1)
Improved Pension Eligibility Verification Report (Veteran with Children) (21-0517-1)
Improved Pension Eligibility Verification Report (Veteran with No Children) (21-0516-1)
Income-Net Worth and Employment Status Statement (21-527)
Income-Net Worth and Employment Status Statement (21-527) (Instructions)
Information Regarding Apportionment of Beneficiary’s Award (21-0788)
Medical Expense Report (21-8416)
Old Law and Section 306 Eligibility Verification Report (Children Only) (21-0513-1)
Old Law and Section 306 Eligibility Verification Report (Surviving Spouse) (21-0512s-1)
Old Law and Section 306 Eligibility Verification Report (Veteran) (21-0512v-1)
Old Law Eligibility Verification Report (Surviving Spouse) (21-0511s-1)
Old Law Eligibility Verification Report (Veteran) (21-0511v-1)
Parent’s DIC Eligibility Verification Report (21-0514-1)
Report of Income from Property or Business (21-4185)
Request for Approval of School Attendance (21-674)
Request for Approval of School Attendance (21-674) (Instructions)
Request for Details of Expenses (21-8049)
Request for Employment Information in Connection with Claim for Disability Benefits (21-4192)
Request for Nursing Home Information in Connection with Claim for Aid and Attendance  (21-0779)
School Attendance Report (21-674b)
Social Security Administration Application For Survivors Benefits (21-534b)
Social Security Administration Application For Survivors Benefits (21-534b) (Instructions)
Statement in Support of Claim (21-4138)
Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (21-0781)
Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (21-0781a)
Statement of Dependency of Parent(s) (21-509)
Statement of Dependency of Parent(s) (21-509) Instructions
Statement of Person Claiming to Have Stood in Relation of Parent (21-524)
Veteran’s Application for Compensation and/or Pension, Part A: General Information (21-526)
Veteran’s Application for Compensation and/or Pension, Part B: Compensation (21-526)
Veteran’s Application for Compensation and/or Pension, Part C: Dependency (21-526)
Veteran’s Application for Compensation and/or Pension, Part D: Pension (21-526)
Veteran’s Application for Compensation and/or Pension (21-526) (Instructions)
Veteran’s Application for Increased Compensation Based on Unemployability (21-8940)

Department of Defense Forms

Application for Correction of Military Record (DD 149)
Application for the Review of Discharge or Dismissal from the Armed Forces (DD 293)
Application for the Review of Discharge or Dismissal from the Armed Forces (DD 293) (Instructions)
Claim for Combat-Related Special Compensation (CRSC) (DD 2860)
Claim for Combat-Related Special Compensation (CRSC) (DD 2860) (Instructions)
Request for Medical/Dental Recordsor Information (DD 877)
Request for Medical/Dental Records From the National Personnel Records Center (NPRC)(DD 877-1)

Other Department of Veterans Affairs Forms

Request for Substitution of Claimant Upon Death of Claimant (21-0847)
Request for Substitution of Claimant Upon Death of Claimant (21-0847) Instructions
Authorization To Disclose Personal Information To a Third Party (21-0845)
Appeal to Board of Veterans’ Appeals (9)
Appeal to Board of Veterans’ Appeals (9) (Instructions)
Application for Accreditation as a Claims Agent (VA-21A)
Application for Accreditation as a Veterans Organization Representative (VA Form 21)
Application for Adaptive Equipment Motor Vehicle (10-1394)
Application for CHAMPVA Benefits (10-10d)
Application for CHAMPVA Benefits (10-10d) (Instructions)
Application for Extended Care Services (10-10EC)
Application for Extended Care Services (10-10EC) (Instructions)
Application for Health Benefits (10-10EZ)
Application for Health Benefits (10-10EZ) (Instructions)
Application for Standard Government Headstone or Marker (40-1330)
Application for Standard Government Headstone or Marker (40-1330) (General Information Sheet)
Application for Survivors Benefits (SSA-24)
Application For Survivors Benefits (SSA-24) (Instructions)
Application of Surviving Spouse or Child for Reps Benefits (21-8924)
Appointment of Individual as Claimant’s Representative (21-22a)
Appointment of Veterans Service Organization as Claimant’s Representative (21-22)
Appointment of Veterans Service Organization as Claimant’s Representative (21-22) (Instructions)
Authorization and Consent to Release Information to the Department of Veterans Affairs (21-4142)
Authorization to Disclose a Record in the Presence of a Third Party (VA Form 5571)
CHAMPVA Other Health Insurance (OHI) Certification (10-7959C)
CHAMPVA Other Health Insurance (OHI) Certification (10-7959C) (Instructions)
Claim for Payment of Cost of Unauthorized Medical Services (10-583)
Examination for Housebound Status or Permanent Need for Regular Aid and Attendance (21-2680)
Financial Status Report (5655)
Foreign Medical Program (FMP) Registration Form (10-7959f-1)
Health Benefits Renewal Form (10-10EZR)
Health Benefits Renewal Form (10-10EZR) (Instructions)
Radiation Risk Activity Information Sheet
Rehabilitation Plan (28-8872)
Rehabilitation Plan--Continuation Sheet (28-8872a)
Request for and Consent to Release of Information from Claimant’s Records (3288)
Request for and Consent to Release of Medical Records Protected by 38 U.S.C. 7332 (10-5345)
Statement of Accredited Representation in Appealed Case (1-646)
Veterans Application For Assistance in Acquiring Home Improvement and Structural Alterations
Veteran’s Application in Acquiring Specially Adapted Housing or Special Home Adapt. Grant (26-4555)

Educational Forms

Application and Enrollment Certification for Individualized Tutorial Assistance (22-1990t)
Application and Enrollment Certification for Individualized Tutorial Assistance (22-1990t) (Inst.)
Application for Refund of Educational Contributions (24-5281)
Application for Survivors’ and Dependents’ Educational Assistance (22-5490)
Application for Survivors’ and Dependents’ Educational Assistance (22-5490) (Instructions)
Application for VA Education Benefits (22-1990)
Application for VA Education Benefits (22-1990) (Instructions)
Application for Work-Study Allowance (22-8691)
Application for Work-Study Allowance (22-8691) (Instructions)
Certificate of Affirmation of Enrollment Agreement--Correspondence Course (22-1999c)
Req. for Change of Program or Place of Training Survivors’ and Dependents’ Educ. Assist. (22-5495)
Req. for Change of Program or Place of Training Survivors’ and Deps’ Educ. Assist. (22-5495) (Inst.)
Request for Change of VA Education Program or Place of Training (22-1995)
Request for Change of VA Education Program or Place of Training (22-1995) (Instructions)
Supplemental Information for Change of Program or Reenrollment (22-8873)
Time Record (Work-Study Program) (22-8690)

Finance Forms

App. for Assump. Approval and/or Release from Personal Liability to Gov’t on a Home Loan (26-6381)
Direct Deposit Enrollment (24-0296)

Home Loan Guaranty Forms

Request for a Certificate of Eligibility for VA Home Loan Benefits (26-1880)
Request for a Certificate of Eligibility for VA Home Loan Benefits (26-1880) (Instructions)
Request for Determination of Loan Guaranty Eligibility--Unmarried Surviving Spouses (26-1817)

Insurance Forms

Service-Disabled Veterans Insurance RH Information and Premum Rates
Application for Cash Surrender Value/or Application for Policy Loan (29-1546)
Application for Service Disabled Insurance (29-4364)
Application for Supplemental Service Disabled Veterans (RH) Life Insurance (29-0189)
Application for Supplemental Service-Disabled Veterans Insurance (SRH) (29-0188)
Application for Veterans’ Group Life Insurance (SGLV 8714)
Application for Veterans’ Group Life Insurance (SGLV 8714) (Instructions)
Claim for Death Benefits (SGLV 8283)
Claim for Death Benefits (SGLV 8283) (Instructions)
Claim for Disability Insurance--Government Life (29-357)
Claim for One Sum Payment (29-4125)
Designation of Beneficiary Government Life Insurance (29-336)
Designation of Beneficiary Government Life Insurance (29-336) (Instructions)
Request for Change of Address/Cancellation of Direct Deposit (20-572)

Miscellaneous Forms

Application for 10-Point Veteran Preference(To be Used by Veterans and Relatives of Veterans)(SF 15)
Application for Relief From Court-Martial Findings and/or Sentence... (DA Form 3499)
Presidential Memorial Certificate Request Form (40-0247)

National Archives Forms

Questionnaire about Military Service (NA 13075)
Request For Information Needed To Reconstruct Medical Data (NA-13055)

Standard Forms

Claim for Damage, Injury, or Death Standard Form (SF 95)
Claim for Unpaid Compensation of Deceased member of the Uniformed Serviced (SF 1174)
Records Transmittal and Receipt (SF135)
Request Pertaining to Military Records (SF 180)
Request Pertaining to Military Records (SF 180) (Instructions)

Vocational Rehabilitation and Employment Forms

Counseling Record - Personal Information (28-1902)
Disabled Veterans Application for Vocational Rehabilitation (28-1900)
Disabled Veterans Application for Vocational Rehabilitation (28-1900) (Instructions)
Employment Questionnaire (21-4140-1)
Rehabilitation Needs Inventory (RNI) (28-1902W)

Additional Forms

Appeal Cancellation Form
Submission Cover Sheet

State Specific Forms

California

Calvet Home Loan Program - Prequalification Application Form
Civil Service Preference (SPB 1093)
Civil Service Preference (SPB 1093) (Instructions)
College Fee Waiver for Veteran’s Dependents
Veterans Home Application
Veterans Home Application (Information)
Veterans’ Special License Plate (Purple Heart, Medal Of Honor) (Reg 17A)

New York

Application for Alternative Veterans Exemption From Real Property Taxation (RP-458-a)
Application for Alternative Veterans’ Exemption From Real Property Taxation (RP-458-a)(Instructions)
Application for New York State Civil Service Examination (Form CC-APP)
Application for New York State Civil Service Examination (Form CC-APP) (Instructions)
Application for Veterans Exemption From Real Property Taxation (RP-458)
Application for Veterans Exemption From Real Property Taxation (RP-458) (Instructions)
Form to Register a Vehicle with Former POW or Congressional Medal of Honor Plates (MV-1H)
Form to Register Motor Vehicle Obtained by Disabled Veteran Under Title 38 U.S.C. (MV-1E)
Form to Renew Registration of Motor Vehicle for Disabled Veteran Under Title 38 (MV-1G)

Texas

Application for "Disabled Veteran" License Plate (VTR-615)
Application for Special License Plate - Purple Heart Recipient or Former POW (VTR-420)
Texas State Veterans Home Application for Admission
Texas Veterans Housing Assistance and Home Improvement Programs, Cert of Eligibility Application
Veteran Status / Veteran’s Employment Preference Form