VA · Official form

VA Form 21-526EZ, Application for Disability Compensation

VA Form 21-526EZ claims disability compensation: tax-free monthly payments for conditions caused or worsened by military service, rated from 0 to 100 percent.

Fill out VA 21-526EZ in the editor Download the blank PDF Quick fill on this page

This is the genuine VA PDF, unmodified. Source: VA official page.

What is VA 21-526EZ?

The 21-526EZ is the veteran’s claim for disability compensation and related benefits. Each claimed condition needs three legs: a current diagnosis, an in-service event or exposure, and a medical link between them, with presumptive conditions (Agent Orange, burn pits under the PACT Act, Gulf War illness) getting the link presumed. The form also handles increases for worsening rated conditions and secondary conditions.

Filing under the Fully Developed Claim track, sending all evidence up front, speeds decisions. An intent to file preserves an effective date up to a year while you gather evidence, and the same claim can be filed online at va.gov.

Who files VA 21-526EZ?

Veterans with conditions connected to their service
Service members within 180 days of separation, under the BDD program
Rated veterans claiming increases or newly developed secondary conditions

How to fill out VA 21-526EZ

List each condition you are claiming and how it relates to service.
Attach or identify evidence: service treatment records, private medical records, buddy statements.
Choose the Fully Developed Claim lane if your evidence is complete.
Download, sign, and mail it to the VA claims intake center, or file at va.gov; attend the compensation exams VA schedules.

Quick fill VA 21-526EZ on this page

Prefer to see the form itself while you type? Open VA 21-526EZ in the editor to fill it on the actual pages, add a signature, and download.

These are the form's own fields, in the order they appear on the pages. Fill in what you know; anything left blank stays a fillable field in the PDF, so you can finish it in any PDF reader. Nothing you type here is sent to VA.

Page 9 48 fields

5. V. A. File Number. Enter nine digit file number.

11. EMAIL ADDRESS (Optional). Line 1.

SECTION 1. VETERAN'S IDENTIFICATION INFORMATION (If claim is not an original claim, only Section 1, 4 (if applicable), and a signature are

2. Veteran / Service Member Name. Enter Last Name.

2. Veteran / Service Member Name. Enter Middle Initial.

3. Social Security Number. Enter first three numbers.

3. Social Security Number. Enter middle two numbers.

3. Social Security Number. Enter last four numbers.

6. Date of Birth. Enter 2 digit Month.

6. Date of Birth. Enter 2 digit day.

6. Date of Birth. Enter 4 digit year.

10. Current Mailing Address. Enter Number and Street.

10. Current Mailing Address. Enter Apartment or Unit Number.

10. Current Mailing Address. Enter City.

10. Current Mailing Address. Enter State or Province.

10. Current Mailing Address. Enter Country.

10. Current Mailing Address. Enter ZIP or Postal Code. First 5 digits.

10. Current Mailing Address. Enter ZIP or Postal Code. Enter last 4 digits.

13. B. New Address. Enter Number and Street.

13. B. New Address. Enter Apartment or Unit Number.

13. B. New Address. Enter City.

13. B. New Address. Enter State or Province.

13. B. New Address. Enter Country.

13. B. New Address. Enter ZIP or Postal Code. First 5 digits.

13. B. New Address. Enter ZIP or Postal Code. Enter last 4 digits.

7. Service Number (If applicable). Enter 9 digits.

8. B. D. D. CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE DUTY. Enter 2 digit Month.

8. B. D. D. CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE DUTY. Enter 4 digit year.

13. C. EFFECTIVE DATE(S) OF NEW ADDRESS (If your change of address is temporary, complete both the beginning and ending date of your

13. C. Beginning Date. Enter 2 digit day.

13. C. Beginning Date. Enter 4 digit year.

13. C. Ending Date. Enter 2 digit Month.

13. C. Ending Date. Enter 2 digit day.

13. C. Ending Date. Enter 4 digit year.

12. IF YOU ARE CURRENTLY A V. A. EMPLOYEE, CHECK THE BOX (Includes Work Study / Internship)? (If you are not a V. A. employee skip to

9. TELEPHONE NUMBER(S) (Optional) (Include Area Code). Enter Area Code.

9. TELEPHONE NUMBER(S). Enter middle three numbers.

9. TELEPHONE NUMBER(S). Enter last four numbers.

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

1. Check box. IDES (Select this option only if you have been referred to the IDES Program by your Military Service Department).

1. Check box. BDD Program Claim. (Select this option only if you meet the criteria for the BDD Program specified on Instruction Page 5).

1. Check box. Standard Claim Process.

8. B. D. D. CLAIMS ONLY: PROVIDE THE DATE OR ANTICIPATED DATE OF RELEASE FROM ACTIVE DUTY. Enter 2 digit Day.

9. Enter International Phone Number (If applicable).

11. Check box. I agree to receive electronic correspondence from VA in regards to my claim.

4. HAVE YOU EVER FILED A CLAIM WITH V. A? Yes. If "Yes," provide your file number in Item 5.

SECTION 2: CHANGE OF ADDRESS. NOTE: If you are temporarily or permanently changing your address, complete Items 13. A. through 13. C. 13.

11. EMAIL ADDRESS (Optional). Line 2.

Page 10 45 fields

Page 11 75 fields

Veteran's Social Security Number. Enter first three numbers.

Veteran's Social Security Number. Enter middle two numbers.

Veteran's Social Security Number. Enter last four numbers.

SECTION 5: CLAIM INFORMATION. 16. CURRENT DISABILITY(IES). Line 1 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 1 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 1 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 1 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 2 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 3 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 4 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 5 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 6 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 7 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 8 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 9 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 10 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 11 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 12 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 13 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 14 of 15.

16. APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 15 of 15.

16. CURRENT DISABILITY. Line 2 of 15.

16. CURRENT DISABILITY. Line 3 of 15.

16. CURRENT DISABILITY. Line 4 of 15.

16. CURRENT DISABILITY. Line 5 of 15.

16. CURRENT DISABILITY. Line 6 of 15.

16. CURRENT DISABILITY. Line 7 of 15.

16. CURRENT DISABILITY. Line 8 of 15.

16. CURRENT DISABILITY. Line 9 of 15.

16. CURRENT DISABILITY. Line 10 of 15.

16. CURRENT DISABILITY. Line 11 of 15.

16. CURRENT DISABILITY. Line 12 of 15.

16. CURRENT DISABILITY. Line 13 of 15.

16. CURRENT DISABILITY. Line 14 of 15.

16. CURRENT DISABILITY. Line 15 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 2 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 3 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 4 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 5 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 6 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 7 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 8 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 9 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 10 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 11 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 12 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 13 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 14 of 15.

16. SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. Line 15 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 2 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 3 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 4 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 5 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 6 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 7 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 8 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 9 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 10 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 11 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 12 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 13 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 14 of 15.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 15 of 15.

17. C. CHECK THE BOX IF YOU DO NOT HAVE DATE OF TREATMENT. Line 1 of 3.

17. C. CHECK THE BOX IF YOU DO NOT HAVE DATE OF TREATMENT. Line 2 of 3.

17. C. CHECK THE BOX IF YOU DO NOT HAVE DATE OF TREATMENT. Line 3 of 3.

17. B. DATE OF TREATMENT. Enter 4 digit year.

17. B. DATE OF TREATMENT. Enter 2 digit Month.

17. B. DATE OF TREATMENT. Enter 4 digit year.

17. B. DATE OF TREATMENT. Enter 2 digit Month.

17. B. DATE OF TREATMENT. Enter 4 digit year.

17. B. DATE OF TREATMENT. Enter 2 digit Month.

17. LIST V. A. MEDICAL CENTER(S) (VAMC) AND DEPARTMENT OF DEFENSE (D O D) MILITARY TREATMENT FACILITIES (M T F) WHERE YOU RECEIVED

Page 12 61 fields

Veteran's Social Security Number. Enter first three numbers.

Veteran's Social Security Number. Enter middle two numbers.

Veteran's Social Security Number. Enter last four numbers.

18. B. LIST THE OTHER NAME(S) YOU SERVED UNDER.

20. A. Most recent active service date(s). Enter 2 digit month.

20. A. Most recent active service date. Enter 2 digit day.

20. A. Most recent active service date. Enter 4 digit Year.

21. C. Obligation Term of Service. From Date. Enter 2 digit month.

21. C. From Date. Enter 2 digit day.

21. C. From Date. Enter 4 digit Year.

21. C. Obligation Term of Service. To Date. Enter 2 digit month.

21. C. To Date. Enter 2 digit day.

21. C. To Date. Enter 4 digit Year.

22. B. Date of Activation. Enter 2 digit month.

22. B. Date of Activation. Enter 2 digit day.

22. B. Date of Activation. Enter 4 digit Year.

22. C. Anticipated separation date. Enter 2 digit month.

22. C. Anticipated separation date. Enter 2 digit day.

22. C. Anticipated separation date. Enter 4 digit Year.

23. B. Dates of confinement. From Date. Enter 2 digit month.

23. B. Dates of confinement. From Date. Enter 2 digit day.

23. B. Dates of confinement. From Date. Enter 4 digit Year.

23. B. Dates of confinement. To Date. Enter 2 digit month.

23. B. Dates of confinement. To Date. Enter 2 digit day.

23. B. Dates of confinement. To Date. Enter 4 digit Year.

23. B. Dates of confinement. From Date. Enter 2 digit month.

23. B. Dates of confinement. From Date. Enter 2 digit day.

23. B. Dates of confinement. From Date. Enter 4 digit Year.

23. B. Dates of confinement. To Date. Enter 2 digit month.

23. B. Dates of confinement. To Date. Enter 2 digit day.

23. B. Dates of confinement. To Date. Enter 4 digit Year.

20. B. Place of last or anticipated separation. Line 1 of 2.

20. B. Place of last or anticipated separation. Line 2 of 2.

20. A. Most recent active service exit date. Enter 2 digit month.

20. A. Most recent active service exit date. Enter 2 digit day.

20. A. Most recent active service exit date. Enter 4 digit Year.

20. C. Additional Periods of Service. From Date. Enter 2 digit month.

20. C. From Date. Enter 2 digit day.

20. C. From Date. Enter 4 digit Year.

20. C. Additional Periods Of Service. To Date. Enter 2 digit month.

20. C. To Date. Enter 2 digit day.

20. C. To Date. Enter 4 digit Year.

SECTION 6. SERVICE INFORMATION. 18. A. DID YOU SERVE UNDER ANOTHER NAME? YES. If "Yes," complete Item 18. B.

20. C. DID YOU SERVE IN A COMBAT ZONE SINCE 9-11-2001? YES.

21. A. ARE YOU CURRENTLY SERVING OR HAVE YOU EVER SERVED IN THE RESERVES OR NATIONAL GUARD? YES. If "Yes," complete Items 21B thru 21F.

21. B. Component. NATIONAL GUARD.

21. F. ARE YOU CURRENTLY RECEIVING INACTIVE DUTY TRAINING PAY? YES.

22. A. ARE YOU CURRENTLY ACTIVATED ON FEDERAL ORDERS WITHIN THE NATIONAL GUARD OR RESERVES? YES. If "Yes," complete Items 22B and 22C.

23. A. HAVE YOU EVER BEEN A PRISONER OF WAR? YES. If "Yes," complete Item 23B.

IMPORTANT INFORMATION ON MILITARY RETIRED PAY (Includes all Uniformed Services Retired Pay): Submission of this application constitutes a

24. D. MONTHLY AMOUNT IN DOLLARS. First 3 digit spaces.

24. D. MONTHLY AMOUNT IN DOLLARS. Last 3 digit spaces.

SECTION 7. SERVICE PAY (Retired Pay, Separation Pay, and Disability Severance Pay). 24. A. Are you receiving military retired pay? Check

24. B. WILL YOU RECEIVE MILITARY RETIRED PAY IN THE FUTURE? YES. If "Yes," explain below (e.g. future Reserve / National Guard retirement,

25. Retired Status. Retired.

21. D. CURRENT OR LAST ASSIGNED NAME AND ADDRESS OF UNIT.

21. E. CURRENT OR ASSIGNED PHONE NUMBER OF UNIT (Include Area Code).

24. B. EXPLAIN.

19. A. BRANCH OF SERVICE. Check box. ARMY

24. C. BRANCH OF SERVICE. Check box. ARMY.

19. B. COMPONENT. Check box. ACTIVE

Page 13 21 fields

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

30. Account Number. Check only one box below and provide the account number. Enter account number.

IMPORTANT INFORMATION ON INACTIVE DUTY TRAINING PAY: You may elect to keep the active or inactive duty training pay you received from the

SECTION 8. DIRECT DEPOSIT INFORMATION. The Department of the Treasury requires all Federal benefit payments be made by electronic funds

27. B. Date payment received. Enter 2 digit month.

27. B. Date payment received. Enter 2 digit day.

27. B. Date payment received. Enter 4 digit Year.

27. D. AMOUNT RECEIVED (Provide pre-tax amount). Last 3 digits.

27. D. AMOUNT RECEIVED (Provide pre-tax amount). First 3 digits.

Veteran's Social Security Number. Enter first three numbers.

Veteran's Social Security Number. Enter middle two numbers.

Veteran's Social Security Number. Enter last four numbers.

IMPORTANT INFORMATION ON SEPARATION / SEVERANCE PAY: V. A. compensation, if granted, may be withheld to recoup any disability severance or

30. CHECKING ACCOUNT.

33. B. DATE SIGNED. Enter 2 digit month.

33. B. DATE SIGNED. Enter 2 digit day.

33. B. DATE SIGNED. Enter 4 digit Year.

34. B. Printed Name and Address of Witness.

35. B. Printed Name and Address of Witness.

31. NAME OF FINANCIAL INSTITUTION (Provide the name of the bank where you want your direct deposit).

27. C. BRANCH OF SERVICE. ARMY

Page 14 9 fields

37. B. DATE SIGNED. Enter 4 digit Year.

37. B. DATE SIGNED. Enter 2 digit day.

37. B. DATE SIGNED. Enter 2 digit month.

36. B. DATE SIGNED. Enter 2 digit month.

36. B. DATE SIGNED. Enter 2 digit day.

36. B. DATE SIGNED. Enter 4 digit Year.

Veteran's Social Security Number. Enter first three numbers.

Veteran's Social Security Number. Enter middle two numbers.

Veteran's Social Security Number. Enter last four numbers.

Page 15 83 fields

Veteran's Social Security Number. Enter first three numbers.

Veteran's Social Security Number. Enter middle two numbers.

Veteran's Social Security Number. Enter last four numbers.

ADDENDUM SECTION 12: CLAIM INFORMATION. CURRENT DISABILITY(IES). Line 1 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits) Line 1 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 1 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 1 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 2 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 3 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 4 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 5 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 6 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 7 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 8 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 9 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 10 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 11 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 12 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 13 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 14 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 15 of 20.

CURRENT DISABILITY. Line 2 of 20.

CURRENT DISABILITY. Line 3 of 20.

CURRENT DISABILITY. Line 4 of 20.

CURRENT DISABILITY. Line 5 of 20.

CURRENT DISABILITY. Line 6 of 20.

CURRENT DISABILITY. Line 7 of 20.

CURRENT DISABILITY. Line 8 of 20.

CURRENT DISABILITY. Line 9 of 20.

CURRENT DISABILITY. Line 10 of 20.

CURRENT DISABILITY. Line 11 of 20.

CURRENT DISABILITY. Line 12 of 20.

CURRENT DISABILITY. Line 13 of 20.

CURRENT DISABILITY. Line 14 of 20.

CURRENT DISABILITY. Line 15 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 2 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 3 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 4 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 5 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 6 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 7 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 8 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 9 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 10 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). PLEASE SPECIFY (e.g., Agent Orange,

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits) Line 12 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 13 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 14 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 15 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 2 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 3 of 20.

16. EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 4 of 15.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 5 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 6 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 7 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 8 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 9 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 10 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 11 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 12 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 13 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 14 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 15 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 16 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 17 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 18 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 19 of 20.

APPROXIMATE DATE DISABILITY BEGAN OR WORSENED. Enter 2 digit month, 2 digit day and 4 digit year. Line 20 of 20.

CURRENT DISABILITY. Line 16 of 20.

CURRENT DISABILITY. Line 17 of 20.

CURRENT DISABILITY. Line 18 of 20.

CURRENT DISABILITY. Line 19 of 20.

CURRENT DISABILITY. Line 20 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 16 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 17 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 18 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 19 of 20.

SPECIFY TYPE OF EXPOSURE, EVENT OR INJURY. PLEASE SPECIFY (e.g., Agent Orange, radiation, burn pits). Line 20 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 16 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 17 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 18 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 19 of 20.

EXPLAIN HOW THE DISABILITY(IES) RELATES TO THE IN-SERVICE EVENT/EXPOSURE/INJURY. Line 20 of 20.

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Frequently asked questions

How is the monthly amount set?

VA rates each condition in 10% steps, combines them with its rating table, and pays by combined rating and dependents. Current rate tables are published at va.gov.

What if my claim is denied?

You have decision review options: supplemental claim with new evidence, higher-level review, or appeal to the Board. Deadlines run one year from the decision, and a supplemental claim can preserve the effective date.

VA Form 21-526EZ, Application for Disability Compensation

What is VA 21-526EZ?

Who files VA 21-526EZ?

How to fill out VA 21-526EZ

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Frequently asked questions

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