Contents
The VBA VA 21-526EZ form is a crucial document for veterans seeking to apply for disability compensation benefits from the Department of Veterans Affairs. This streamlined application process is designed to simplify the submission of claims, ensuring that veterans can access the support they deserve with minimal barriers. With its user-friendly format, the form allows veterans to provide essential information about their service-related injuries or illnesses efficiently. Key sections of the form include personal identification details, military service history, and specific information regarding the disabilities being claimed. Additionally, the form emphasizes the importance of providing supporting evidence, which can significantly influence the outcome of the claim. By understanding the purpose and components of the VBA VA 21-526EZ form, veterans can better navigate the application process and enhance their chances of receiving timely benefits.
Preview - VBA VA 21-526EZ Form
When submitting a claim(s) for Veterans Disability Compensation and Related Compensation Benefits the following information tells you what you
need to do and what VA will do during the FDC Program (Optional Expedited Process) or the Standard Claim Process:
1. HOW TO SUBMIT A CLAIM
Submit your claim on a VA Form 21-526EZ (Attached). Make sure you complete and sign your application. The information on pages 2 through 8
describes the evidence you need to submit, how VA will help you obtain evidence and what the evidence must show to support your claim.
2. WHAT YOU NEED TO DO
The table on page 2 describes the information and evidence you need to submit based on whether you wish to have your claim considered in the FDC
Program (Optional Expedited Process) or in the Standard Claim Process. You will need to indicate how you want your claim to be processed by
checking the appropriate box in Item 1, on page 9 of this form.
Want to apply electronically? You can apply online at www.va.gov. If you sign in or create an account, we can prefill parts of your application and
save your work in progress. You can also upload all your supporting documents with your claim, and submit it through the Fully Developed Claims
(FDC) program, then track claim status online. Get Started at https://www.va.gov/disability/how-to-file-claim/.
NOTE: You may wish to contact an accredited veterans service officer (VSO) to assist you with your application. For a list of accredited veterans
service organizations go to https://www.va.gov/ogc/recognizedvsos.asp. You may also contact your state office of veterans affairs at
https://www.va.gov/statedva.htm, should you need further assistance with the application process.
Want your claim processed faster? The FDC Program is the fastest way to get your claim processed without any risk to participate! To participate in
making a claim for veterans disability compensation or related compensation benefits, submit your claim in accordance with the "FDC Program" shown
on the following information pages 2 through 8. If you are making a claim for veterans non service-connected pension benefits, use VA Form
21P-527EZ, Application for Pension. If you are making a claim for survivor benefits, use VA Form 21P-534EZ, Application for DIC, Death Pension,
and/or Accrued Benefits. VA forms are available at www.va.gov/vaforms. A separate expedited claims processing program available for current active
duty Servicemembers is explained on page 5 under Compensation Claims Submitted Prior to Discharge.
NOTE: Participation in the FDC Program is optional and will not affect the benefits to which you are entitled. If you file a claim in the FDC Program
and it is determined that other records exist and VA needs the records to decide your claim, then VA will simply remove the claim from the FDC
Program and process it in the Standard Claim Process. If you wish to file your claim in the FDC Program, see FDC Program (Optional Expedited
Process) on page 2 . If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim Process on page 2.
NOTICE TO VETERAN/SERVICE MEMBER OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
VETERANS DISABILITY COMPENSATION AND RELATED COMPENSATION BENEFITS
VA FORM
NOV 2022
21-526EZ
Page 1
SUPERSEDES VA FORM 21-526EZ, SEP 2019.
This notice provides information regarding the evidence necessary to substantiate a claim for:
Compensation Claims Submitted Prior to Discharge
Disability Service Connection
Benefits Based on a Veteran's Seriously Disabled Child
Increased Disability Compensation
Individual Unemployability
Special Monthly Compensation
Specially Adapted Housing/Special Home Adaptation
Automobile Allowance/Adaptive Equipment
Presumptive Service Connection
Compensation under 38 U.S.C. 1151
Secondary Service Compensation
Temporary Total Disability Rating
SUBMITTING A CLAIM
When to Use this Form
Use this notice and the attached application to submit a claim for veterans' disability compensation and related compensation benefits. This
notice informs you of the evidence necessary to decide your claim. After you submit your claim on the attached application you will not receive
an initial letter regarding your claim. You do not need to submit another application.
please complete and submit VA Form 20-0995, Decision
Review Request: Supplemental Claim**
If you are filing a new claim or a claim for increased
disability compensation for an evaluation decided
more than one year ago ...
If you disagree with an evaluation decided within the
past year and have new and relevant evidence OR
If you are filing a supplemental claim (a claim after an
initial claim for the same or similar benefit was
previously decided) and have new and relevant
evidence ...
please complete and submit VA Form 21-526EZ,
Application for Disability Compensation and Related
Compensation Benefits.
** You may also file a request for higher-level review (VA Form 20-0996, Decision Review Request: Higher-Level Review) or appeal to the Board of
Veterans' Appeals (VA Form 10182, Decision Review Request: Board Appeals (Notice of Disagreement)). For additional information on all of these
different options, please visit https://www.va.gov/decision-reviews/.
SPECIAL CIRCUMSTANCES
VA FORM 21-526EZ, NOV 2022 Page 2
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
• 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 any mental health conditions(s), submit a completed VA Form 21-0781, Statement in Support of Claimed Mental Health
Disorder(s) Due to an In-Service Traumatic Event(s).
FDC Program (Optional Expedited Process) Standard Claim Process
You must:
• Submit all relevant private treatment records, if they exist
• Identify any relevant treatment records available at a Federal
Facility, such as a VA medical center
• Identify the location and sufficient information to obtain your
National Guard and Reserve personnel and service treatment
records (if applicable)
If your claim involves a disability that you had before entering service
and that was made worse by service, please provide any information or
evidence in your possession regarding the health condition that existed
before your entry into service.
NOTE: If you decide to submit your claim through the FDC Program,
please indicate FDC in Item 1 of the application on page 8.
If you know of evidence not in your possession and want VA to try to get
it for you;
You must:
• Complete and sign VA Form 21-4142, Authorization to Disclose
Information to the Department of Veterans Affairs (VA) and VA Form
21-4142a, General Release for Medical Provider Information to the
Department of Veterans Affairs (VA), identifying any private medical
records you wish VA to request for you
• Give VA enough information about other relevant evidence so that we
can request it from the person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a fee to
provide it, or otherwise cannot get the evidence, VA will notify you and
provide you with an opportunity to submit the information or evidence. It
is your responsibility to make sure we receive all requested records that
are not in the possession of a Federal department or agency.
If your claim involves a disability that you had before entering service and
that was made worse by service, please provide any information or
evidence in your possession regarding the health condition that existed
before your entry into service.
You must:
• Send the information and evidence along with your claim
If you submit additional information or evidence after you submit your
"fully developed" claim, then VA will remove the claim from the FDC
Program (Optional Expedited Process) and process it in the Standard
Claim Process. If we decide your claim before one year from the date
we receive the claim, you will still have the remainder of the one-year
period to submit additional information or evidence necessary to
support the claim.
You are strongly encouraged to:
• Send any information or evidence as soon as you can
You have up to one year from the date we receive the claim to submit the
information and evidence necessary to support your claim. If within 30
days, you do not provide any evidence or do not provide us with the
information needed to assist you with obtaining evidence, we may decide
your claim prior to the expiration of the one year period. If we decide the
claim before one year from the date we receive the claim, you will still
have the remainder of the one year period to submit additional information
or evidence necessary to support the claim.
If any of the special circumstances in the table below titled "Special
Circumstances" applies to you;
You must:
• Send the information and evidence identified in the "Special
Circumstances" table below at the same time as your claim
If any of the special circumstances in the table below titled "Special
Circumstances" applies to you;
You are strongly encouraged to:
• Send the information and evidence identified in the "Special
Circumstances" table below at the same time as your claim. If you do
not submit the needed information or evidence with your claim but it is
needed to make a decision, VA will request it from you.
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.
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 the following methods shown in the table below.
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.
SPECIAL CIRCUMSTANCES (Continued)
MAIL TO
SUBMIT ONLINE
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
FDC Program (Optional Expedited Process) Standard Claim Process
VA will:
• Retrieve relevant records from a Federal facility, such as a VA
medical center, that you adequately identify and authorized VA to
obtain
• Provide a medical examination for you, or get a medical opinion, if
we determine it is necessary to decide your claim
VA will:
• Retrieve relevant records from a Federal facility, such as a VA medical
center, that you adequately identify and authorized VA to obtain
• Provide a medical examination for you, or get a medical opinion, if we
determine it is necessary to decide your claim
• Make every reasonable effort to obtain relevant records not held by a
Federal facility that you adequately identify and authorize VA to
obtain. These may include records from State or local governments and
privately held evidence and information you tell us about, such as a
private doctor or hospital records from current or former employers
VA gov: www.va.gov
Direct Upload: AccessVA
If you are claiming... See the evidence table titled...
Individual Unemployability
You have a qualifying disability that arose as a result of a presumption
of exposure
You have a disability that was caused or aggravated by your service Disability Service Connection
Your service-connected disability(ies) causes you to be in need of aid and
attendance or the be confined to your residence
You have a disability caused or aggravated by VA medical treatment,
vocational rehabilitation, or compensated work therapy
Adapting and/or purchasing a residence
Adapting and/or purchasing a vehicle
Presumptive Service Connection
Secondary Service Connection
Compensation Claims Submitted Prior to Discharge
Temporary Total Disability Rating
Increased Disability Compensation
Compensation Under 38 U.S.C. 1151
Special Monthly Compensation
Special Adapted Housing or Special Home Adaptation
Special Monthly Compensation
Helpless Child
Your service-connected disability caused or aggravated an additional
disability
Your service-connected disability has worsened
Compensation and you are a service person who is about to be discharged
Your service-connected disability caused you to be hospitalized or to
undergo surgery or other treatment
Your service-connected disability(ies) prevents you from getting or
keeping substantial employment
A Severely Disabled Spouse
Auto Allowance
A Severely Disabled Child
VA FORM 21-526EZ, NOV 2022 Page 3
Disability Service Connection
To support a claim for service connection, the evidence must show:
VA FORM 21-526EZ, NOV 2022 Page 4
EVIDENCE TABLES
To support a claim for service connection based upon a period of active duty for training, the evidence must show:
To support a claim for service connection based upon a period of inactive duty training, the evidence must show:
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.
Presumptive Service Connection
• You served in a recognized location that qualifies you for the presumption of exposure; AND/OR
To support a claim for presumptive service connection the evidence must show:
• You have a current disability that qualifies you for the presumption of service connection. This may be shown by medical evidence or by lay
evidence of persistent and recurrent symptoms of disability that are visible or observable.
Under certain circumstances, VA may presume that certain current diseases were caused by service, even if there is no specific evidence proving
this in your particular claim. Service connection is presumed for certain diseases for the following veterans:
• 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 service in/on:
o Vietnam or qualifying offshore waters, from January 9, 1962, through May 7, 1975;
o a unit determined by VA or the Department of Defense to have operated in the Korean DMZ, from September 1, 1967, through
August 31, 1971;
o individuals who performed service in the Air Force or Air Force Reserve and regularly and repeatedly operated, maintained, or
served onboard C-123 aircraft known to have used to spray an herbicide agent during the Vietnam era;
o Thailand at any United States or Royal Thai base, from January 9, 1962, through June 30, 1976;
o Laos, from December 1, 1965, through September 30, 1969;
o Cambodia at Mimot or Krek, Kampong Cham Province, from April 16, 1969, through April 30, 1969;
o Guam or American Samoa, or in the territorial waters thereof, from January 9, 1962, through July 31, 1980;
o Johnston Atoll or on a ship that called at Johnston Atoll, from January 1, 1972, through September 30, 1977.
• 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.
• 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
• 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 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.
• 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 be considered relevant, the additional evidence must tend to prove or disprove a matter at issue in the claim.
• Veterans who served in the Gulf War:
• Veterans who served at Camp Lejeune for no less than 30 days (consecutive or nonconsecutive) between August 1, 1953 and December 31,
1987; or
o On or after August 2, 1990, and served in:
o On or after September 11, 2001, and served in:
§ Bahrain; Iraq; the neutral zone between Iraq and Saudi Arabia; Kuwait; Oman; Qatar; Saudi Arabia; Somalia; United Arab
Emirates; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; the Red Sea; Afghanistan; Israel; Egypt;
Turkey; Syria; or Jordan; OR
§ Afghanistan; Djibouti; Egypt; Jordan; Lebanon; Syria; Yemen; or Uzbekistan.
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.
VA FORM 21-526EZ, NOV 2022 Page 5
EVIDENCE TABLES (Continued)
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 required convalescence of at least one month; OR
• One major joint or more was immobilized by a cast without surgery.
• 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
• The surgery or treatment was for a service-connected disability; AND
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.
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;
• complete a VA Form 21-526EZ.
• provide an anticipated release from active duty date; and
• submit copies of service treatment records for the current period of service with the BDD claim;
• be available to report for examinations for 45 days following the submission of a disability claim;
Individual Unemployability
In order to support a claim for a total disability rating based on individual unemployability, the evidence must show:
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 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).
• 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.
• provide a completed Separation Health Assessment - Part A Self Assessment
(obtain from: www.benefits.va.gov/compensation/dbq_publicdbqs.asp);
VA FORM 21-526EZ, NOV 2022 Page 6
EVIDENCE TABLES (Continued)
Compensation Under 38 U.S.C. 1151
• 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 Veterans Readiness and Employment or compensated work therapy program.
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:
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:
• 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
• Amyotrophic lateral sclerosis (ALS); OR
• Loss or loss of use of both upper extremities precluding use of the arms at or above the elbow; OR
• A severe burn injury, meaning full thickness or sub-dermal burns that have resulted in contractures with limitation of motion of:
o two or more extremities; OR
o at least one extremity and the trunk.
• Loss (amputation) or loss of use of:
o both lower extremities; OR
o one lower extremity and one upper extremity affecting balance or propulsion; OR
o 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
EVIDENCE TABLES (Continued)
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.
• 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.
• Loss (amputation) or loss of use of:
o 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 that you have a qualifying condition under the alternative service criteria the evidence must show:
To support your claim for a special home adaptation (SHA) grant the evidence must show you are a:
• 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
o 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
o 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
o residuals of inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease).
To support that you have a qualifying condition for SHA the evidence must show:
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.
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:
• the loss, or permanent loss of use, of at least a foot or a hand; OR
• permanent impairment of vision of both eyes, resulting in:
o vision of 20/200 or less in the better eye with corrective glasses; OR
o vision of 20/200 or better, if there is a severe defect in your peripheral vision; OR
• 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
• amyotrophic lateral sclerosis (ALS).
Page 7 VA FORM 21-526EZ, NOV 2022
Specially Adapted Housing or Special Home Adaptation (Continued)
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:
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.
• When we received your claim; OR
• When the evidence shows a level of disability that supports a certain rating under the rating schedule.
6. ADDITIONAL INFORMATION
How VA Determines the 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:
• Statements discussing your disability symptoms from people who have witnessed how the symptoms affect you.
• 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
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:
For more information on VA benefits, visit our web site at www.va.gov.
You are entitled to a hearing at any time in the claims process. If you wish to have a hearing or have other questions, contact VA online through
Ask VA: https://ask.va.gov or call us toll-free at 1-800-827-1000 (TTY:711).
VA forms are available at www.va.gov/vaforms.
Page 8
VA FORM 21-526EZ, NOV 2022
SECTION II: CHANGE OF ADDRESS
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
(If claim is not an original claim, only Section I, IV (if applicable), V and a signature are required)
Page 9
OMB Control No. 2900-0747
Respondent Burden: 25 minutes
Expiration Date: 11/30/2025
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
IMPORTANT: Please read the Privacy Act and Respondent Burden on Page 14 before completing the form. Use this form to
determine your eligibility for compensation. For more information, you can contact us online through Ask VA: https://ask.va.gov.
Ask us a question online or call us toll-free at 1-800-827-1000 (TTY: 711). If you prefer you may complete and submit the form online
at
www.va.gov. VA forms are available at www.va.gov/vaforms.
2. VETERAN/SERVICEMEMBER'S NAME (First, Middle Initial, Last)
3. SOCIAL SECURITY NUMBER (SSN)
6. DATE OF BIRTH (MM-DD-YYYY)
4. HAVE YOU EVER FILED A CLAIM WITH VA?
(If "Yes," provide your file
number in Item 5)
5. VA FILE NUMBER
11. EMAIL ADDRESS (Optional)
APPLICATION FOR DISABILITY COMPENSATION AND RELATED
COMPENSATION BENEFITS
10. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
13B. NEW ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
9. TELEPHONE NUMBER
(Optional) (Include Area Code)
VA FORM
NOV 2022
SUPERSEDES VA FORM 21-526EZ, SEP 2019.
21-526EZ
No. &
Street
Apt./Unit Number City
ZIP Code/Postal Code
State/Province
Country
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
7. SERVICE NUMBER/DOD ID NUMBER (If applicable)
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly, insert one
letter per box, and completely fill in each applicable check box to help expedite processing of the form.
8. BDD CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF
RELEASE FROM ACTIVE DUTY (MM-DD-YYYY)
13A. TYPE OF ADDRESS CHANGE (Complete if applicable) (Check only one box)
NOTE: If you are temporarily or permanently changing your address, complete Items 13A through 13C.
13C. 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)
Year
Day
Month
BEGINNING DATE:
ENDING DATE:
Year
Day
Month
12. 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).
FDC PROGRAM
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)
STANDARD CLAIM PROCESS
Enter International Phone Number (If applicable)
I agree to receive electronic correspondence from VA in regards to my claim.
YES NO
TEMPORARY
PERMANENT
1. SELECT THE TYPE OF CLAIM PROGRAM/PROCESS THAT APPLIES TO YOU. NOTE: Your claim will be processed as described on pages 1 through 8 unless one of
the following special programs is selected. See Instruction pages 1 through 3 for definitions of the Fully Developed Claim (FDC) Program (Optional Expedited Process) or the
Standard Claim Process.
SECTION III: HOMELESS INFORMATION
IMPORTANT: The following questions (Items 14A through 14F) should only be completed if you are currently homeless or at risk of becoming homeless.
If this item does not apply to you, skip to Section IV.
Page 10
VA FORM 21-526EZ, NOV 2022
VETERAN'S SOCIAL SECURITY NO.
14A. ARE YOU CURRENTLY HOMELESS?
(If "Yes," complete Item 14B regarding your living situation)
14B. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:
14C. ARE YOU CURRENTLY AT RISK OF BECOMING HOMELESS?
(If "Yes," complete Item 14D regarding your living situation)
14D. CHECK THE BOX THAT APPLIES TO YOUR LIVING SITUATION:
14E. POINT OF CONTACT (Name of person VA can contact in order to get in touch with you)
14F. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code)
LIVING IN A HOMELESS SHELTER
NOT CURRENTLY IN A SHELTERED ENVIRONMENT (e.g., living in a
car or tent)
STAYING WITH ANOTHER PERSON
FLEEING CURRENT RESIDENCE
OTHER (Specify)
HOUSING WILL BE LOST IN 30 DAYS
LEAVING PUBLICLY FUNDED SYSTEM OF CARE (e.g., homeless
shelter)
OTHER (Specify)
YES
NO
YES
NO
Enter International Phone Number
(If applicable)
15A. ARE YOU CLAIMING ANY CONDITIONS RELATED TO TOXIC EXPOSURES? NOTE: See Page 4 of the Instructions for further information on the evidence needed to
support your claim for presumptive service connection. (You can also refer to the following websites for more information: PACT ACT (https://www.va.gov/PACT) and
PUBLIC HEALTH MILITARY EXPOSURES (https://www.publichealth.va.gov/exposures/index.asp))
SECTION IV: EXPOSURE INFORMATION
YES (If "Yes," complete Items 15B, 15C, 15D and 15E) NO (If "No," skip to Item 16, Section V: Claim Information)
YES NO
15B. DID YOU SERVE IN ANY OF THE FOLLOWING GULF WAR HAZARD LOCATIONS?
Iraq; Kuwait; Saudi Arabia; the neutral zone between Iraq and Saudi Arabia; Bahrain; Qatar; the United Arab Emirates; Oman; Yemen; Lebanon; Somalia; Afghanistan;
Israel; Egypt; Turkey; Syria; Jordan; Djibouti; Uzbekistan; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; and the Red Sea.
WHEN DID YOU SERVE IN THESE LOCATIONS? (MM-YYYY)
Note: Please provide an approximate time frame (month and year).
YES NO
Please list other location(s) where you served, if not listed above:
ASBESTOS
MILITARY OCCUPATIONAL SPECIALTY (MOS)-related toxin
SHAD (Shipboard Hazard and Defense)
CONTAMINATED WATER AT CAMP LEJEUNE
OTHER (Specify)
MUSTARD GAS
15D. HAVE YOU BEEN EXPOSED TO ANY OF THE FOLLOWING? (Check all that apply)
15E. IF YOU WERE EXPOSED MULTIPLE TIMES, PLEASE PROVIDE ALL ADDITIONAL DATES AND LOCATIONS OF POTENTIAL EXPOSURE
JULY 1968
Example 3. LEFT KNEE, SECONDARY TO RIGHT KNEE
Example 2. DIABETES
Example 1. HEARING LOSS
6/11/2008
EXAMPLES OF DISABILITY(IES)
DECEMBER 1972
16. LIST THE CURRENT DISABILITY(IES) OR SYMPTOMS THAT YOU CLAIM ARE RELATED TO YOUR MILITARY SERVICE AND/OR SERVICE-CONNECTED
DISABILITY (If applicable, identify whether a disability is due to a service-connected disability; confinement as a prisoner of war; exposure to Agent Orange, asbestos, mustard
gas, ionizing radiation, or Gulf War environmental hazards; or a disability for which compensation is payable under 38 U.S.C. 1151)
NOTE: List your claimed conditions below. See the following three examples for guidance on how to complete Section V.
EXAMPLES OF EXPOSURE
TYPE
EXAMPLES OF DATES
NOISE HEAVY EQUIPMENT OPERATOR IN SERVICE
AGENT ORANGE SERVICE IN VIETNAM WAR
INJURED LEFT KNEE WHEN BRACE ON
RIGHT KNEE FAILED
EXAMPLES OF HOW THE
DISABILITY(IES) RELATES TO SERVICE
SECTION V: CLAIM INFORMATION
(For additional space, use Section XIII: Claim Information (Addendum))
FROM:
TO:
WHEN DID YOU SERVE IN THESE LOCATIONS? (MM-YYYY)
Note: Please provide an approximate time frame (month and year).
FROM: TO:
RADIATION
WHEN WERE YOU EXPOSED? (MM-YYYY)
Note: Please provide an approximate time-frame (month and year).
FROM: TO:
15C. DID YOU SERVE IN ANY OF THE FOLLOWING HERBICIDE (e.g., Agent Orange) LOCATIONS?
Republic of Vietnam to include the 12 nautical mile territorial waters; Thailand at any United States or Royal Thai base; Laos; Cambodia at Mimot or Krek; Kampong Cham
Province; Guam or American Samoa; or in the territorial waters thereof; Johnston Atoll or a ship that called at Johnston Atoll; Korean demilitarized zone; aboard (to include
repeated operations and maintenance with) a C-123 aircraft known to have been used to spray an herbicide agent (during service in the Air Force and Air Force Reserves).
Document Specifics
| Fact Name | Description |
|---|---|
| Purpose | The VA Form 21-526EZ is used by veterans to apply for disability compensation and related benefits. |
| Eligibility | To use this form, you must be a veteran who has served in active military, naval, or air service. |
| Filing Method | This form can be submitted online through the VA's website, by mail, or in person at a regional office. |
| Supporting Documents | Along with the form, you may need to provide medical evidence and service records to support your claim. |
| Processing Time | After submission, the processing time can vary, but it typically takes several months to receive a decision. |
| State-Specific Forms | Some states may have additional forms required for specific benefits. Check local regulations for details. |
| Governing Laws | Federal law governs the VA benefits process, primarily Title 38 of the United States Code. |
| Signature Requirement | A signature is required on the form to certify that the information provided is true and complete. |
| Contact Information | If you have questions, you can contact the VA directly or visit their website for assistance. |
VBA VA 21-526EZ: Usage Instruction
Filling out the VBA VA 21-526EZ form is an important step in the process of applying for benefits. Ensure you have all necessary information at hand before you begin. This will help make the process smoother and quicker.
- Gather personal information, including your full name, Social Security number, and contact details.
- Identify your military service details, such as the branch of service, service dates, and discharge status.
- Provide information about your dependents, including their names, Social Security numbers, and relationship to you.
- Detail any medical conditions or disabilities you are claiming. Be specific about how these conditions affect your daily life.
- Include any relevant medical treatment history, including names of doctors and facilities where you received care.
- Review the form carefully to ensure all information is accurate and complete.
- Sign and date the form. Make sure to sign in the designated area.
- Submit the form as instructed, either online or by mailing it to the appropriate address.
Learn More on VBA VA 21-526EZ
What is the VBA VA 21-526EZ form?
The VBA VA 21-526EZ form is a streamlined application used by veterans to apply for disability compensation benefits from the Department of Veterans Affairs (VA). This form simplifies the process for veterans, allowing them to provide necessary information about their service-related disabilities and expedite the claims process.
Who is eligible to use the VA 21-526EZ form?
Eligibility for using the VA 21-526EZ form generally includes veterans who have served in active military, naval, or air service and have a current disability that is connected to their service. Additionally, certain dependents may also qualify to apply for benefits on behalf of the veteran.
How do I obtain the VA 21-526EZ form?
The VA 21-526EZ form can be obtained from several sources:
- The official VA website, where it is available for download.
- Local VA offices, which can provide printed copies.
- Veterans Service Organizations (VSOs) that assist with claims.
What information do I need to complete the form?
To complete the VA 21-526EZ form, you will need to provide the following information:
- Your personal identification details, including name, Social Security number, and address.
- Details about your military service, such as dates of service and branch.
- Information about your current disabilities, including medical records and treatment history.
- Any additional supporting documents that substantiate your claim.
Can I submit the VA 21-526EZ form online?
Yes, the VA allows veterans to submit the VA 21-526EZ form online through the VA’s eBenefits portal. This method is often faster and more efficient, as it allows for immediate submission and tracking of your application status.
What happens after I submit the form?
After submission, the VA will review your application. They may contact you for additional information or schedule a medical examination to assess your disability. Once the review is complete, you will receive a decision regarding your claim, typically via mail.
How long does it take to process the VA 21-526EZ form?
The processing time for the VA 21-526EZ form can vary. Generally, it may take several months, depending on the complexity of your claim and the current workload of the VA. You can check the status of your claim through the VA’s website or by contacting their office directly.
What if my claim is denied?
If your claim is denied, you have the right to appeal the decision. The VA will provide instructions on how to proceed with an appeal, which may involve submitting additional evidence or requesting a hearing. It is advisable to seek assistance from a VSO or legal professional to navigate the appeals process effectively.
Common mistakes
Filling out the VBA VA 21-526EZ form can be a daunting task for many veterans. One common mistake is failing to provide complete and accurate personal information. This includes not only your name and address but also your Social Security number and service details. Missing or incorrect information can delay the processing of your claim and may even result in a denial.
Another frequent error is neglecting to sign and date the form. It might seem trivial, but without your signature, the application is incomplete. This simple oversight can lead to unnecessary delays in the review process. Always double-check that you have signed and dated the form before submission.
Many individuals also overlook the importance of including all necessary supporting documents. The VBA VA 21-526EZ requires various forms of evidence to support your claim, such as medical records or service documentation. Failing to attach these documents can hinder your claim's progress and may require you to resubmit the entire application.
In addition, some applicants misinterpret the questions on the form. It’s essential to read each question carefully and provide clear, concise answers. Ambiguities can lead to misunderstandings and may result in a denial of benefits. If you are unsure about how to answer a question, seeking assistance can be beneficial.
Lastly, many people do not keep a copy of their completed form. This can be problematic if you need to reference your application later or if there are questions about what you submitted. Always retain a copy for your records to ensure you have the information readily available if needed.
Documents used along the form
The VBA VA 21-526EZ form is essential for veterans seeking disability compensation from the Department of Veterans Affairs. To ensure a smooth application process, several other documents may be needed to support the claim. Below is a list of commonly used forms and documents that accompany the VA 21-526EZ form.
- VA Form 21-4138: This is a statement in support of claim. Veterans can use it to provide additional information or evidence that supports their disability claim.
- VA Form 21-4142: This form allows veterans to authorize the release of their private medical records from healthcare providers. It is crucial for obtaining relevant medical evidence.
- VA Form 21-526EZ (Continuation Sheet): Sometimes, additional information is necessary. This continuation sheet allows veterans to provide more details about their claim if the original form is not sufficient.
- DD Form 214: This document serves as proof of military service. It outlines the veteran's service dates, discharge status, and other essential details that are necessary for the claim process.
- Medical Records: Veterans should gather their medical records, including treatment history and diagnoses. These documents help establish the connection between military service and the claimed disability.
- Dependency Documentation: If claiming benefits for dependents, veterans must provide documentation such as marriage certificates or birth certificates to verify the relationship.
Gathering these documents can significantly enhance the chances of a successful claim. Each form plays a unique role in providing the necessary evidence and support for the application process.
Similar forms
The VBA VA 21-526EZ form is primarily used by veterans to apply for disability compensation benefits. It is similar to the VA Form 21-526, which is the standard application for veterans seeking disability compensation. While both forms serve the same purpose, the 21-526EZ is designed to simplify the application process by eliminating unnecessary questions and focusing on essential information needed for a quicker review. This streamlined approach helps veterans receive their benefits more efficiently.
Another related document is the VA Form 21-527EZ, which is used for veterans applying for pension benefits. Like the 21-526EZ, this form is structured to expedite the application process. It requires less information than the traditional pension application, making it easier for veterans to submit their claims and receive timely assistance. Both forms reflect the VA's commitment to simplifying access to benefits for those who have served.
The VA Form 21-534EZ is also comparable, as it is used for survivors of veterans applying for Dependency and Indemnity Compensation (DIC) benefits. This form shares the same streamlined approach as the 21-526EZ, focusing on essential details to facilitate a quicker decision. By reducing the complexity of the application, the VA aims to support surviving spouses and dependents in their time of need.
Similarly, the VA Form 21-4142 is utilized to authorize the release of medical records. This document is crucial for veterans applying for benefits, as it allows the VA to obtain necessary medical evidence to support a claim. While it serves a different purpose than the 21-526EZ, both forms play a vital role in ensuring that veterans receive the benefits they deserve based on their medical history.
The VA Form 21-22 is another important document, which designates a representative to assist veterans in their claims process. While it does not directly relate to the application for benefits, having a representative can significantly enhance the likelihood of a successful claim. This form complements the 21-526EZ by ensuring that veterans have the support they need throughout the application process.
The VA Form 21-0845 allows veterans to authorize the VA to disclose their information to a third party. This form is particularly useful when veterans want family members or advocates to be involved in their claims. It shares a similar goal with the 21-526EZ, which is to facilitate the claims process and ensure that veterans receive the support they need from trusted individuals.
Lastly, the VA Form 21-0966 is used for filing a supplemental claim. This document is relevant for veterans who wish to appeal a decision made by the VA regarding their benefits. While it serves a different function than the 21-526EZ, both forms are essential in the broader context of the claims process. They reflect the various stages veterans may encounter as they seek to secure their rightful benefits.
Dos and Don'ts
When filling out the VBA VA 21-526EZ form, it is important to follow certain guidelines to ensure your application is processed smoothly. Here is a list of what you should and shouldn't do:
- Do: Read the instructions carefully before starting.
- Do: Provide accurate and complete information.
- Do: Use black ink and write legibly.
- Do: Double-check your Social Security number for accuracy.
- Do: Sign and date the form where indicated.
- Don't: Leave any required fields blank.
- Don't: Use abbreviations unless specified in the instructions.
- Don't: Submit the form without making copies for your records.
- Don't: Forget to include any supporting documents that are required.
By following these guidelines, you can help ensure that your application is complete and that the review process goes as smoothly as possible.
Misconceptions
The VBA VA 21-526EZ form is essential for veterans seeking disability compensation. However, several misconceptions can lead to confusion. Here are five common misunderstandings about this form:
- Myth 1: The 21-526EZ form is only for veterans with service-related injuries.
- Myth 2: Completing the 21-526EZ form guarantees approval for benefits.
- Myth 3: The form must be filled out perfectly on the first attempt.
- Myth 4: You can only submit the 21-526EZ form once.
- Myth 5: Assistance is not available for filling out the form.
This is not entirely accurate. While the form is primarily used for veterans seeking compensation for service-connected disabilities, it can also be used for certain non-service-related conditions in specific circumstances.
Submitting the form does not ensure that benefits will be granted. The approval process involves a thorough review of the application, medical evidence, and service records.
This is misleading. Veterans can submit the form multiple times if they need to update their claims or if their circumstances change.
In reality, there are many resources available. Veterans can seek help from veteran service organizations, online resources, and VA representatives to guide them through the process.
Key takeaways
The VBA VA 21-526EZ form is a crucial document for veterans seeking disability compensation. Understanding how to fill it out correctly can streamline the application process. Here are some key takeaways to consider:
- Eligibility Requirements: Before filling out the form, ensure you meet the eligibility criteria for VA disability benefits.
- Personal Information: Provide accurate personal details, including your full name, Social Security number, and contact information.
- Service History: Document your military service, including branch, dates of service, and any deployments.
- Disability Information: Clearly describe the disabilities you are claiming, including how they relate to your military service.
- Supporting Documents: Gather necessary documentation, such as medical records and service treatment records, to support your claim.
- Signature Requirement: Ensure that you sign and date the form. An unsigned form may delay processing.
- Submission Methods: Be aware of the various ways to submit the form, including online, by mail, or in person at a regional VA office.
Completing the VBA VA 21-526EZ form accurately can significantly impact the outcome of your claim. Take the time to review each section thoroughly before submission.