Form 21-526c Pre-Discharge Compensation Claim

OMB Approved No. 2900Respondent Burden: 15 minutes

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

PRE-DISCHARGE COMPENSATION CLAIM
(For use only with Benefits Delivery at Discharge (BDD) or Quick Start Claims)
IMPORTANT: Please read the Privacy Act and Respondent Burden on the back before
completing the form.

BDD/Quick Start (Circle one)

SECTION I: To be completed by service member
1. SERVICE MEMBER NAME (Last, first, middle)

2. PLACE OF SEPARATION

3. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM,DD,YYYY)

5. SEX
MALE

6A. CURRENT ADDRESS

FEMALE

6B. TELEPHONE NUMBERS (Include Area Code)

Street address, rural route, or P.O. Box

Daytime

(

)

Evening

(

)

Apt. number

City
State
7A. WORK E-MAIL ADDRESS (If applicable)

(
)
Cell phone
Country
7B. PERSONAL E-MAIL ADDRESS (If applicable)

ZIP Code

8B. TELEPHONE NUMBER

8A. FORWARDING ADDRESS

9A. NAME AND RELATIONSHIP OF NEXT
OF KIN

9B. ADDRESS OF NEXT OF KIN

9C. TELEPHONE NUMBER
OF NEXT OF KIN

10A. HAVE YOU EVER FILED A CLAIM WITH VA?
YES
NO
(If "Yes," provide your file number in Item 10B)

10B. VA FILE NUMBER

11. WHAT DISABILITIES ARE YOU CLAIMING? SUBMIT ADDITIONAL SUPPORTING STATEMENTS AND INFORMATION
CONCERNING YOUR CLAIMED DISABILITIES ON VA FORM 21-4138, STATEMENT IN SUPPORT OF CLAIM

IMPORTANT: If claiming dependents, please attach a completed VA Form 21-686c, Declaration of Status of Dependents.
SECTION II: SERVICE INFORMATION
12A. DID YOU SERVE UNDER ANOTHER NAME?
YES (If "Yes," go to Item 12B)
NO (If "No," go to Item 13A)
13A. I ENTERED THIS CURRENT PERIOD OF
ACTIVE SERVICE ON (MM,DD,YYYY)

mo

day

12B. PLEASE LIST OTHER NAME(S) YOU SERVED UNDER

13B. BRANCH OF SERVICE

13C. ANTICIPATED DATE
OF RELEASE FROM
ACTIVE DUTY

yr

14A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
AUTHORITY OF TITLE 10, U.S.C.?
YES

NO

(If "Yes," provide date of activation in Item 14B)

15A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?

YES

NO

mo

day

yr

15B. WHAT IS THE TELEPHONE
NUMBER OF YOUR CURRENT
UNIT? (Include Area Code)

)

16B. I PREVIOUSLY ENTERED ACTIVE SERVICE
ON (MM,DD,YYYY)

(If "No," go to Item 17A)

mo
VA FORM
JUL 2009

NO

14B. DATE OF ACTIVATION (MM,DD,YYYY)

(
16A. DO YOU HAVE ADDITIONAL PERIODS OF ACTIVE SERVICE?
YES (If "Yes," go to Item 16B)

13D.DID YOU SERVE IN A
COMBAT ZONE SINCE
9-11-2001?

21-526c

day

yr

SECTION III: MILITARY RETIRED PAY
17B. TYPE OF RETIRED PAY?
LONGEVITY
DISABILITY

17A. WILL YOU RECEIVE RETIRED PAY?
YES

NO

YES

NO

TDRL

(If "Yes," complete Item 17B)

18A. WILL YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE PAY?

18B. LIST AMOUNT (If known)

18C. LIST TYPE (If known)

(If "Yes," complete Items 18B and 18C)

IMPORTANT: Unless you check the box in Item 19 below, you are telling us that you are choosing to receive VA compensation
instead of military retired pay, if it is determined you are entitled to both benefits. If you are awarded military retired pay prior to
compensation, we will reduce your retired pay by that amount. VA will notify the Military Retired Pay Center of all benefit changes.
If you receive both military retired pay and VA compensation, some of the amount you get may be recouped by VA, or, in the case of
Voluntary Separation Incentive (VSI), by the Department of Defense.
19.

No, I do not want VA compensation in lieu of military retired pay.
SECTION IV: DIRECT DEPOSIT INFORMATION

Generally, all Federal payments are required to be made by electronic funds transfer (EFT), also called Direct Deposit. Please attach a voided
personal check or deposit slip or provide the information requested below in Items 20, 21 and 22 to enroll in Direct Deposit. If you do not have a
bank account, we will give you a waiver from Direct Deposit, just check the box below in Item 20. The Treasury Department is working to make
bank accounts available in such situations. Once these accounts are available, you will be able to decide whether you wish to sign-up for one of the
accounts or continue to receive a paper check. You can also request a waiver if you have other circumstances that you feel would cause a hardship if
you enrolled in Direct Deposit. You can write to: Department of Veterans Affairs, 125 S. Main Street, Suite B, Muskogee, OK 74401-7004, and give
us a brief description of why you do not wish to participate in Direct Deposit.
20. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)
CHECKING_____________________

SAVINGS_________________________

21. NAME OF FINANCIAL INSTITUTION (Please provide the name of
the bank where you want your direct deposit)

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT
WITH A FINANCIAL INSTITUTION OR CERTIFIED
PAYMENT AGENT

22. ROUTING OR TRANSIT NUMBER (The first nine numbers located
at the bottom left of your check)

SECTION V: CERTIFICATIONS AND SIGNATURE
I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I
authorize any person or entity, including but not limited to any organization, service provider, employer, or government agency, to give the
Department of Veterans Affairs any information about me except protected health information, and I waive any privilege which makes the
information confidential.
23A. YOUR SIGNATURE (Do NOT print)

23B. DATE SIGNED

SECTION VI: WITNESSES TO SIGNATURE
24A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

24B. PRINTED NAME AND ADDRESS OF WITNESS

25A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

25B. PRINTED NAME AND ADDRESS OF WITNESS

PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The responses you submit are considered
confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under
the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation
and Employment Records - VA. The requested information is considered relevant and necessary to determine maximum benefits under the law. Information submitted
is subject to verification through computer matching programs with other agencies. VA may make a "routine use" disclosure for: civil or criminal law enforcement,
congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party
or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration. Your obligation to
respond is required in order to obtain or retain benefits. Information that you furnish may be utilized in computer matching programs with other Federal or state
agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your
participation in any benefit program administered by the Department of Veterans Affairs. Social Security information: You are required to provide the Social Security
number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may disclose them for
purposes stated above.
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you
can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-526c, JUL 2009