TRUTH IN FILING

All information you provide must be true and accurate.  There may be delays for withholding information or giving false information.  There may be penalties enforced for perjury in regards to citizenship or erroneous military information.  The information you submit will create a claim record for you in our system.

*Name: *Address: *City: *State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Samoa Virgin Islands Zip: Telephone: Cellular: *E-mail: *Date of Birth (mm/dd/yyyy): *Social Security Number: *Military Branch: Air Force Army Coast Guard Marine Corps Merchant Marine Navy *Era of Hostilities: World War II Korea Vietnam Lebanon Grenada Panama Persian Gulf Somalia Yugoslavia Bosnia Iraq Global War on Terroism *Dates of Military Service: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 - January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 I am applying for: Service-Connected Disability Non Service-Connected Disability VA Pension Other *Describe your disability.  What caused it and how it affects the performance of your duty. *Required By submitting your information on this form you certify that it is correct and hereby authorize an ICP or a physician who has attended me or may attend me, or any hospital where I may have been a patient to disclose any information thus acquired to an ICP, at no expense to U.S. Veterans Compensation Programs.  A photcopy of this authorization shall be considered valid as the original.