Blank VBA VA 21-526EZ PDF Template

SPECIAL CIRCUMSTANCES

Under the special circumstances shown below, you must also submit along with your claim the following:

•If you were treated at a Veterans Center, submit a completed VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA)

•If claiming dependents, submit a completed VA Form 21-686c, Application Request to Add and/or Remove Dependents. If claiming a child in school between the ages of 18 and 23; also submit a completed VA Form 21-674, Request for Approval of School Attendance. If

claiming benefits for a seriously disabled (helpless) child, also submit all, relevant, private medical treatment records pertaining to the child's pertinent disabilities

•If claiming Individual Unemployability, submit a completed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability

•If claiming Post-Traumatic Stress Disorder (PTSD), submit a completed VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder, or if claiming PTSD based on personal assault, submit a completed VA Form 21-0781a, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault

SPECIAL CIRCUMSTANCES (Continued)

Under the special circumstances shown below, you must also submit along with your claim the following:

•If claiming Specially Adapted Housing or Special Home Adaptation, submit a completed VA Form 26-4555, Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant

•If claiming Auto Allowance, submit a completed VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment

•If claiming additional benefits because you or your spouse require Aid and Attendance, submit a completed VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance; or if claiming Aid and Attendance based on nursing home attendance, a VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance

NOTE: VA forms are available online at www.va.gov/vaforms.

3.HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM

The table below describes the information and evidence VA will assist you in obtaining based on whether you wish to have your claim considered in the FDC Program (Optional Expedited Process) or in the Standard Claim Process.

4. WHERE TO SEND INFORMATION AND EVIDENCE

You may send your application and any evidence in support of your claim by using any of the following methods shown in the table below.

5. WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM

The table below provides a guide to the evidence tables showing what evidence you must provide to support your claim.

EVIDENCE TABLES

Disability Service Connection

To support a claim for service connection, the evidence must show:

•You had an injury in service, or a disease that began in or was made permanently worse during service, or there was an event in service that caused an injury or disease; AND

•You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent symptoms of disability that are visible or observable; AND

•A relationship exists between your current disability and an injury, disease, symptoms, or event in service. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.

However, under certain circumstances, VA may presume that certain current disabilities were caused by service, even if there is no specific evidence proving this in your particular claim. The cause of a disability is presumed for the following veterans who have certain diseases:

•Former prisoners of war;

•Veterans who have certain chronic or tropical diseases that become evident within a specific period of time after discharge from service;

•Veterans who were exposed to ionizing radiation, mustard gas, or Lewisite while in service;

•Veterans who were exposed to certain herbicides, such as by serving in Vietnam; or

•Veterans who served at Camp Lejeune for no less than 30 days (consecutive or nonconsecutive) between August 1, 1953 and December 31, 1987; or

•Veterans who served in the Southwest Asia theater of operations during the Gulf War.

To support a claim for service connection based upon a period of active duty for training, the evidence must show:

•You were disabled during active duty for training due to disease or injury incurred or aggravated in the line of duty; AND

•You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent symptoms of disability that are visible or observable; AND

•There is a relationship between your current disability and the disease or injury incurred or aggravated during active duty for training. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.

To support a claim for service connection based upon a period of inactive duty training, the evidence must show:

•You were disabled during inactive duty training due to an injury incurred or aggravated in the line of duty or an acute myocardial infarction, cardiac arrest, or cerebrovascular accident during inactive duty training; AND

•You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and recurrent symptoms of disability that are visible or observable; AND

•There is a relationship between your current disability and your inactive duty training. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.

In order to file a supplemental claim, you must submit or identify new and relevant evidence.

•To qualify as new, the evidence must not have been part of the evidentiary record at the time of the prior decision.

•In order to be considered relevant, the additional evidence must tend to prove or disprove a matter at issue in the claim.

Secondary Service Connection

To support a claim for compensation based upon an additional disability that was caused or aggravated by a service-connected disability, the evidence must show:

•You currently have a physical or mental disability shown by medical evidence or by lay evidence of persistent and recurrent symptoms of disability that are visible or observable, in addition to your service-connected disability; AND

•Your service-connected disability either caused or aggravated your additional disability. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence. However, VA may presume service-connection for cardiovascular disease developing in a claimant with certain service-connected amputation(s) of one or both lower extremities.

Increased Disability Compensation

If VA previously granted service connection for your disability and you are seeking an increased evaluation of your service-connected disability, we need medical or lay evidence to show a worsening or increase in severity and the effect that worsening or increase has on your ability to work.

EVIDENCE TABLES (Continued)

Compensation Claims Submitted Prior to Discharge

Under the Benefits Delivery at Discharge (BDD) program you can submit a disability claim 90 to 180 days prior to your anticipated separation date from active duty. Claims are accepted from active duty Servicemembers, including reservists serving on active duty in an Active Guard Reserve (AGR) role under 10 U.S.C. and full-time National Guard members serving in an AGR role under 32 U.S.C.

BDD program participants can have their VA medical examinations conducted while they are still on active duty. You are encouraged to file your claim as close to the 180 day mark as possible to ensure your examinations can be scheduled and completed prior to your discharge from active duty. The BDD program requires that Servicemembers be available to report for examinations for 45 days following submission of a disability claim. Claims and additional contentions received with less than 90 days remaining on active duty, claim types that are excluded from the BDD program, or where the Servicemember is unable to report for an examination within the BDD required time frame will be processed under the standard VA claims process, the Fully Developed Claim (FDC) program or any other qualifying program.

BDD Program Criteria for Claim(s) for Disability Compensation and Related Compensation Benefits Submitted Prior to Separation from Active Duty:

•be within 90 to 180 days of discharge;

•be available to report for examinations for 45 days following the submission of a disability claim;

•provide an anticipated release from active duty date, and

•complete a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits

Temporary Total Disability Rating

In order to support a claim for a temporary total disability rating due to hospitalization, the evidence must show:

•You were treated for more than 21 days for a service-connected disability at a VA or other approved hospital; OR

•You underwent hospital observation at VA expense for a service-connected disability for more than 21 days.

In order to support a claim for a temporary total disability rating due to surgical or other treatment performed by a VA or other approved hospital or outpatient facility, the evidence must show:

•The surgery or treatment was for a service-connected disability; AND

•The surgery required convalescence of at least one month; OR

•The surgery resulted in severe postoperative residuals, such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilizations, house confinement, or the required use of a wheelchair or crutches; OR

•One major joint or more was immobilized by a cast without surgery.

Individual Unemployability

In order to support a claim for a total disability rating based on individual unemployability, the evidence must show:

•That your service-connected disability or disabilities are sufficient, without regard to other factors, to prevent you from performing the mental and/or physical tasks required to get or keep substantially gainful employment; AND

•Generally, you meet certain disability percentage requirements as specified in 38 Code of Federal Regulations 4.16 (i.e. one disability ratable at 60 percent or more, OR more than one disability with one disability ratable at 40 percent or more and a combined rating of 70 percent or more).

In order to support a claim for an extra-scheduler evaluation based on exceptional circumstances, the evidence must show:

•That your service-connected disability or disabilities present such an exceptional or unusual disability picture, due to such factors as marked interference with employment or frequent periods of hospitalization, that application of the regular schedular standards is impractical.

Compensation Under 38 U.S.C. 1151

In order to support a claim for compensation under 38 U.S.C. 1151, the evidence must show that, as a result of VA hospitalization, medical or surgical treatment, examination, or training, you have:

•An additional disability or disabilities; OR

•An aggravation of an existing injury or disease; AND

•The disability was the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment, or not a reasonably expected result or complication of the VA care or treatment; OR

•The direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy program.

EVIDENCE TABLES (Continued)

Special Monthly Compensation

In order to support a claim for increased benefits based on the need for aid and attendance, the evidence must show that, due to your service- connected disability or disabilities:

•You require the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing yourself, attending to the wants of nature, adjusting prosthetic devices, or protecting yourself from the hazards of your daily environment (38 Code of Federal Regulation 3.352(a)); OR

•You are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed course of convalescence or treatment (38 Code of Federal Regulation 3.352(a)).

In order to support a claim for increased benefits based on an additional disability or being housebound, the evidence must show:

•You have a single service-connected disability evaluated as 100 percent disabling AND an additional service-connected disability, or disabilities, evaluated as 60 percent or more disabling; OR

•You have a single service-connected disability evaluated as 100 percent disabling AND, due solely to your service-connected disability or disabilities, you are permanently and substantially confined to your immediate premises.

In order to support a claim for increased benefits based on your spouse's need for aid and attendance, per the provisions of 38 C.F.R. § 3.351(c), the evidence must show:

•Your spouse is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; OR

•Your spouse is a patient in a nursing home because of mental or physical incapacity; OR

•Your spouse requires the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the hazards of his or her daily environment (See 38 C.F.R. § 3.352(a) for complete explanation).

IMPORTANT: For additional benefits to be payable for a spouse, the veteran must be entitled to compensation and evaluated as 30 percent or more disabling.

Specially Adapted Housing or Special Home Adaptation

To support your claim for specially adapted housing (SAH), the evidence must show you are a:

•Veteran entitled to compensation under 38 U.S.C. Chapter 11 for a permanent and totally disabling qualifying condition; OR

•Servicemember on active duty who has a permanent and totally disabling qualifying condition incurred or aggravated in the line of duty.

To support that you have a qualifying condition for SAH the evidence must show:

•Amyotrophic lateral sclerosis (ALS); OR

•Loss (amputation) or loss of use of:

•both lower extremities; OR

•one lower extremity and one upper extremity affecting balance or propulsion; OR

•one lower extremity plus residuals of organic disease or injury affecting balance or propulsion creating a need for regular, constant use of a wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other methods may occasionally be possible); OR

•Loss or loss of use of both upper extremities precluding use of the arms at or above the elbow; OR

•Permanent but not total disability due to blindness in both eyes, (having central visual acuity of 20/200 or less in the better eye with the use of a standard correcting lens); OR

•A severe burn injury, meaning full thickness or sub-dermal burns that have resulted in contractures with limitation of motion of:

•two or more extremities; OR

•at least one extremity and the trunk.

To support your claim for SAH the evidence may alternatively show you are a:

•Veteran who served and became permanently disabled from a qualifying condition on or after September 11, 2001; OR

•Servicemember on active duty who was permanently disabled in the line of duty from a qualifying condition on or after the same date.

To support that you have a qualifying condition under the alternative service criteria the evidence must show:

•Loss (amputation) or loss of use of:

•one or more lower extremities, severely affecting the functions of balance or propulsion and creating a need for regular, constant use of a wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other methods may occasionally be possible).

To support your claim for a special home adaptation (SHA) grant the evidence must show you are a:

•Veteran entitled to compensation under 38 U.S.C. Chapter 11 for a qualifying condition; OR

•Servicemember on active duty who has a qualifying condition incurred or aggravated in the line of duty.

EVIDENCE TABLES (Continued)

Specially Adapted Housing or Special Home Adaptation (Continued)

To support that you have a qualifying condition for SHA the evidence must show:

•the loss, or permanent loss of use, of at least a foot or a hand; OR

•Permanent and total disability from loss, or loss of use, of both hands; OR

•Permanent and total disability from a severe burn injury meaning

•deep partial thickness burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; OR

•full thickness or sub-dermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk; OR

•residuals of inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease).

Auto Allowance

To support a claim for automobile allowance or adaptive equipment, the evidence must show that you have a service-connected disability resulting in:

(1)the loss, or permanent loss of use, of at least a foot or a hand; OR

(2)permanent impairment of vision of both eyes, resulting in:

(a)vision of 20/200 or less in the better eye with corrective glasses; OR

(b)vision of 20/200 or better, if there is a severe defect in your peripheral vision; OR

(3)deep partial thickness or full thickness burns resulting in scar formation that cause contractures and limit motion of one or more extremities of the trunk and preclude effective operation of an automobile; OR

(4)amyotrophic lateral sclerosis (ALS).

NOTE - You may be entitled to only adaptive equipment if you have ankylosis ("freezing") of at least one knee or one hip due to service-connected disability. Medical evidence, including a VA examination, will show these things. VA will provide an examination if it determines that one is necessary.

Helpless Child

To support a claim for benefits based on a veteran's child being helpless, the evidence must show that the child, before his or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.

IMPORTANT: For additional benefits to be payable for a child, the veteran must be entitled to compensation and evaluated as 30 percent or more disabling.

HOW VA DETERMINES THE EFFECTIVE DATE.

If we grant your claim, the beginning date of your entitlement or increased entitlement to benefits will generally be based on the following factors:

•When we received your claim, OR

•When the evidence shows a level of disability that supports a certain rating under the rating schedule

If VA received your claim prior to or within one year of your separation from the military, entitlement will be from the day following the date of your separation as long as the disability was present at that time.

HOW VA DETERMINES THE DISABILITY RATING.

When we find disabilities to be service-connected, we assign a disability rating. That rating can be changed if there are changes in your condition. Depending on the disability involved, we will assign a rating from 0 percent to as much as 100 percent. VA uses a schedule for evaluating disabilities that is published as title 38, Code of Federal Regulations, Part 4. In rare cases, we can assign a disability level other than the levels found in the schedule for a specific condition if your impairment is not adequately covered by the schedule.

We consider evidence of the following in determining disability rating:

•Nature and symptoms of the condition;

•Severity and duration of the symptoms; AND

•Impact of the condition and symptoms on employment.

Examples of evidence that you should tell us about or give to us that may affect how we assign a disability evaluation include the following:

•Information about on-going treatment records, including VA or other Federal treatment records, you have not previously told us about;

•Social Security determinations;

•Statements from employers as to job performance, lost time, or other information regarding how your condition(s) affect your ability to work; OR

•Statements discussing your disability symptoms from people who have witnessed how the symptoms affect you.

For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/.

For more information on VA benefits, visit our web site at www.va.gov, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available at www.va.gov/vaforms.

IMPORTANT: If you wish to make a claim for veterans non service-connected pension benefits because you have little or no income, use VA Form 21P-527EZ, Application for Pension. VA forms are available at www.va.gov/vaforms. If you cannot access this form, write the word "Pension" in Item 16, or at the top of the attached application and VA will send you the form.

OMB Control No. 2900-0747 Respondent Burden: 25 minutes Expiration Date: 09/30/2022

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)

NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.

SECTION I: IDENTIFICATION AND CLAIM INFORMATION

(If claim is not an original claim, only Section I, IV, and a signature are required)

2.VETERAN/SERVICE MEMBER NAME (First, Middle Initial, Last)

11.CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. & Street

13. 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)

SECTION II: CHANGE OF ADDRESS

NOTE: If you are temporarily or permanently changing your address, complete Items 14A through 14C.

14A. TYPE OF ADDRESS CHANGE (Complete if applicable) (Check only one box)

TEMPORARY PERMANENT

14B. NEW ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

14C. EFFECTIVE DATE(S) OF NEW ADDRESS (If your change of address is temporary, complete both the beginning and ending date of your temporary address) (If your change of address is permanent, please enter your effective date in the beginning date only)