Fillable Printable Vba 21 0304 Are
Fillable Printable Vba 21 0304 Are
Vba 21 0304 Are
APPLICATION FOR BENEFITS FOR CERTAIN
CHILDREN WITH DISABILITIES BORN OF
VIETNAM AND CERTAIN KOREA SERVICE VETERANS
OMB Approved 2900-0572
Respondent Burden: 10 minutes
Expiration Date: 06/30/2019
VA FORM
JUN 2016
21-0304
1. NAME OF CLAIMANT - CHILD (First, middle, last) 2. SOCIAL SECURITY NUMBER OF CLAIMANT - CHILD (If available)
3. CLAIMANT - CHILD'S DATE OF BIRTH
4. CLAIMANT - CHILD'S PLACE OF BIRTH
(City and State)
5. ADDRESS OF CLAIMANT - CHILD (Include number and street or rural route, city or P.O., State and ZIP Code)
6. TELEPHONE NUMBER OF CLAIMANT - CHILD (Include Area Code)
7. NAME(S) OF NATURAL PARENT(S) (Please provide information for both)
B. MOTHER (First, middle, last)A. FATHER (First, middle, last)
B. MOTHER (Include number and street or rural route, city or P.O., State and
ZIP Code)
8. ADDRESS, TELEPHONE NUMBER AND VETERAN STATUS OF NATURAL PARENT(S)
A. FATHER B. MOTHER
9. SOCIAL SECURITY NUMBER(S) OF NATURAL PARENT(S)
B. MOTHER
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10. VA CLAIM NUMBER(S) OF NATURAL PARENT(S) (If veteran previously applied to VA for any benefit)
D. VIETNAM SERVICE? C. VIETNAM SERVICE?
NOYESYES NO
F. PLEASE PROVIDE THE DATES THAT CHILD'S MOTHER WAS IN VIETNAM
(If "Yes", provide dates in 8F)
A. FATHER (Include number and street or rural route, city or P.O., State and
ZIP Code)
E. PLEASE PROVIDE THE DATES THAT CHILD'S FATHER WAS IN VIETNAM
TO
(If "Yes", provide dates in 8E)
FROM FROM
A. FATHER
TO
SUPERSEDES VA FORM 21-0304, SEP 2006,
WHICH WILL NOT BE USED.
NOTE - After completing the form mail to: VA Regional Office, Veterans Service Center (339/21), Box 25126, Denver, CO 80225
Privacy Act Notice: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
Title 5, Code of Federal Regulations 1.526 for routine uses (i.e., 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) as identified in the VA system of records, 58VA21/22 Compensation, Pension, Education,
and Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN
account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). The VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect.
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.
Respondent Burden: We need this information to determine eligibility for benefits for children with certain disabilities who are born of Vietnam veterans and certain
Korea Service veterans (38 U.S.C. chapter 18). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 10
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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions
about this form.
DIRECT DEPOSIT INFORMATION
Account Number:
12A. IF CLAIMANT-CHILD IS AGE 18 OR OLDER HAS THE CLAIMANT-CHILD BEEN DECLARED INCOMPETENT?
I/We, the undersigned, hereby authorize the hospital or physician shown in Items 14, 15A and 16A to disclose and release to the Department of
Veterans Affairs any information that may have been obtained in connection with the physical examination or treatment of the child.
11. IF CHILD IS UNDER AGE 18 WHO HAS CUSTODY, IF OTHER THAN NATURAL PARENT? (Complete Items 11A, 11B & 11C)
A. NAME OF CUSTODIAN/GUARDIAN OF
CLAIMANT-CHILD
B. RELATIONSHIP TO CHILD C. ADDRESS OF CUSTODIAN/GUARDIAN OF CLAIMANT-CHILD
NO
(If "Yes", complete Items 12B and 12C)
YES
ADOPTIVE PARENT
OTHER
(Specify)
GUARDIAN
12B. NAME AND ADDRESS OF THE COURT WHICH MADE THE FINDING OF INCOMPETENCY? 12C. NAME AND ADDRESS OF GUARDIAN
13. DISABILITIES CLAIMED
14. NAME AND ADDRESS OF PRIMARY HEALTH CARE PROVIDER FOR THE CLAIMANT
15A. NAME AND PLACE FIRST DIAGNOSED 15B. DATE FIRST DIAGNOSED
16B. DATE(S) OF TREATMENT16A. NAME(S) AND PLACE(S) OF MOST RECENT TREATMENT
I/We, the undersigned, declare under penalty of perjury that the information provided is true and correct and that the child named in Item 1 is the natural
child of the person(s) named in Item 7.
21A. SIGNATURE OF VIETNAM VETERAN PARENT (IF AVAILABLE OR DIFFERENT)
20B. DATE SIGNED
19A. SIGNATURE OF WITNESS
(Required)
18B. DATE SIGNED
21B. DATE SIGNED
18A. SIGNATURE(S) OF PARENT/GUARDIAN/ADULT CHILD
19B. DATE SIGNED
20A. SIGNATURE OF CHILD
(IF AN ADULT) OR PARENT OR GUARDIAN
The Department of Treasury requires all Federal benefit payments 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 17A, 17B and 17C
to enroll in direct deposit. If you do not have a bank account, you must receive your payment through Direct Express Debit MasterCard.
To request a Direct Express Debit MasterCard you must apply at www.usdirectexpress.com
or by telephone at 1-800-333-1795. If you
elect not to enroll, you must contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They
will encourage your participation in EFT and address any questions or concerns you may have.
17B. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank where you want your direct deposit)
17A. ACCOUNT NUMBER
(Please check the appropriate box and provide that account number, if applicable)
17C. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the bottom left of your check)
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT
WITH A FINANCIAL INSTITUTION OR CERTIFIED
PAYMENT AGENT
CHECKING
SAVINGS
VA FORM 21-0304, JUN 2016
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Account Number:
APPLICATION INFORMATION AND INSTRUCTIONS FOR VA FORM 21-0304
Children of Women Vietnam Veterans Born with Certain Birth Defects -- 38 U.S.C. 1815
This section of the law authorizes the payment of monetary benefits to, or on behalf of, certain children of female veterans who served in
Vietnam. Benefits are payable to qualifying children, or on their behalf, beginning December 1, 2001. There are three eligibility
requirements. To be eligible, the child must:
• be the biological child of a woman veteran who served in the Republic of Vietnam (RVN),
• have been conceived after the date the veteran first served in the RVN during the period 2/28/61 to 5/7/75, and
• have certain birth defects identified by the Secretary of Veterans Affairs as resulting in permanent physical or mental disability
The law does not include conditions that are:
• a familial disorder
• a birth-related injury, or
• a fetal or neonatal infirmity with well-established causes.
Completion of VA Form 21-0304, Application For Benefits For Certain Children Of Vietnam Veterans With Disabilities, is required.
The effective date is December 1, 2001.
Possible Entitlement: The law does not allow payment of both benefits at the same time. If entitlement exists under both laws, benefits
will be paid under 38 U.S.C. 1815.
Health Coverage: The law allows health care covering the defects or any disability associated with the birth defects. This care may be
provided directly or by contract.
Vocational Rehabilitation: If achievement of a vocational goal is reasonably feasible, a program of vocational training provided by VA's
Vocational Rehabilitation and Employment Service is available to an eligible child.
Monetary Allowance: The law includes levels of monetary allowance, each based on the level of disability of the eligible child.
Mail The Completed Form To:
VA Regional Office
Veterans Service Center (339/21)
Box 25126
Denver, CO 80225
IMPORTANT - Please read information and instructions before completing attached application.
Spina Bifida Benefits Eligibility -- 38 U.S.C. 1805
Monetary benefits may be paid to, or on behalf of, certain children of veterans who served in the Republic of Vietnam or the demilitarized
zone in Korea during the Vietnam era. Benefits are payable to qualifying children regardless of age or marital status. To be eligible, the
child must:
• be the biological child of a veteran who served in the Republic of Vietnam (RVN), or a veteran who served in or near the demilitarized
zone (DMZ) in Korea and was exposed to herbicides, and
• have been conceived after the date the veteran first served in the RVN during the period 1/9/62 and 5/7/75, or after the date the veteran
first served in or near the DMZ in Korea during the period 9/1/67 to 8/31/71, and
• have any type of spina bifida other than spina bifida occulta. The diagnosis may be established by private physicians, or government or
private institution examination reports.
VA FORM 21-0304, JUN 2016
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