Fillable Printable Vba 21 0972 Are
Fillable Printable Vba 21 0972 Are
Vba 21 0972 Are
NOTE: For more information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us
toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
NOTICE TO VETERAN/CLAIMANT OF VA FORMS THAT MAY ACCOMPANY
AN ALTERNATE SIGNER CERTIFICATION FORM
IMPORTANT: The form(s) shown below will be accepted along with the attached VA Form 21-0972, Alternate Signer Certification.
VA forms are available at www.va.gov/vaforms
.
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VA FORM 21-0972, OCT 2016
For COMPENSATION, the required forms are:
•
VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits
• VA Form 21-526b, Veteran's Supplemental Claim for Compensation
• VA Form 21-526c, Pre-Discharge Compensation Claim
For PENSION, the required forms are:
•
VA Form 21-527EZ, Application for Pension
• VA Form 21-527, Income, Net Worth, and Employment Statement
• VA Form 21P-0969, Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and Indemnity Compensation (DIC)
• VA Form 21P-4165, Pension Claim Questionnaire for Farm Income
• VA Form 21-8049, Request for Details of Expenses
• VA Form 21P-8416, Medical Expense Report
• VA Form 21-4185, Report of Income from Property or Business
• ALL forms known as Eligibility Verification Reports (EVR's)
For COMPENSATION AND/OR PENSION, the required forms are:
• VA Form 21-526, Veterans Application for Compensation and/or Pension
• VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC
For DEPENDENTS, the required forms are:
•
VA Form 21-686c, Declaration of Status of Dependents
For SCHOOL AGE CHILD(REN) (Aged 18-23 Years and In School), the required forms are:
•
VA Form 21-674, Request for Approval of School Attendance
For DEPENDENT PARENT(S), the required forms are:
• VA Form 21P-509, Statement of Dependency of Parent(s)
For INDIVIDUAL UNEMPLOYABILITY), the required forms are:
• VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability
For POST-TRAUMATIC STRESS DISORDER, the required forms are:
• VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) and VA Form 21-0781a,
Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault
For SPECIALLY ADAPTED HOUSING OR SPECIAL HOME ADAPTATION, the required forms are:
• VA Form 26-4555, Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant
For AUTO ALLOWANCE, the required forms are:
• VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment
For SURVIVORS BENEFITS the required forms are:
•
VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefi t
• VA Form 21-534, Application for Dependency and Indemnity Compensation, Death Pension, and Accrued Benefits by Surviving Spouse or Child
• VA Form 21-534a, Application for Dependency and Indemnity Compensation by a Surviving Spouse or Child - In-Service Death Only
• VA Form 21-535, Application for Dependency and Indemnity Compensation by Parent(s)
• VA Form 21-8924, Application of Surviving Spouse or Child for REPS Benefits (Restored Entitlement Program for Survivors)
For ACCRUED BENEFITS the required forms are:
• VA Form 21-601, Application for Accrued Amounts Due a Deceased Beneficiary
For PHILIPPINE CLAIMS the required forms are:
• VA Form 21-0704, Supplemental Income Questionnaire
• VA Form 21-4169, Supplement to VA Forms 21-526, 21-534, and 21-535
For BENEFITS FOR CERTAIN CHILDREN WITH DISABILITIES the required forms are:
• VA Form 21-0304, Application for Benefits for Certain Children with Disabilities Born of Vietnam and Certain Korea Service Veterans
11. CLAIMANT'S PREFERRED TELEPHONE NUMBER (Include Area Code)
SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION (Complete This Section If The Claimant is Other Than The Veteran)
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VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
ALTERNATE SIGNER CERTIFICATION
8. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
1. VETERAN'S NAME (First, middle initial, last)
Month
Day
Year
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print your information using blue or black ink, neatly, and legibly to help process the form.
4. VETERAN'S DATE OF BIRTH
3. VA FILE NUMBER (If applicable)
2. VETERAN'S SOCIAL SECURITY NUMBER
INSTRUCTIONS: This form is to be completed by the individual signing the benefit application form on
behalf of the veteran/claimant. Note: For purposes of this form, the individual signing the form on behalf
of the veteran/claimant is referred to as the "alternate signer." Your accurate and complete answers to the
questions on this form are important to help VA complete the veteran/claimant's claim.
No. &
Street
Apt./Unit Number
State/Province
Country ZIP Code/Postal Code
City
OMB Control No. 2900-0849
Respondent Burden: 15 minutes
Expiration Date: 10/31/2019
IMPORTANT: Submit this form along with the appropriate benefit application form. The application form depends on the benefit you are claiming on behalf
of the veteran/claimant. Also, submit any supporting documents or evidence to help VA complete the claim. See page 1 for a list of appropriate benefit
application forms.
21-0972
VA FORM
OCT 2016
5. HAS THE VETERAN EVER FILED A CLAIM WITH VA?
YES NO
6. VETERAN'S SERVICE NUMBER (If applicable)
7. CLAIMANT'S NAME (First, middle initial, last)
9. CLAIMANT'S SOCIAL SECURITY NUMBER
10. CLAIMANT'S RELATIONSHIP TO VETERAN
SPOUSE
PARENT
12. CLAIMANT'S PREFERRED E-MAIL ADDRESS (If applicable)
SECTION III: ALTERNATE SIGNER'S IDENTIFICATION INFORMATION
13. ALTERNATE SIGNER'S NAME (First, middle initial, last)
14. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province
Country ZIP Code/Postal Code
City
15. ALTERNATE SIGNER'S PREFERRED TELEPHONE NUMBER (Include Area Code)
16. ALTERNATE SIGNER'S PREFERRED E-MAIL ADDRESS
(If applicable)
17. ALTERNATE SIGNER'S RELATIONSHIP TO VETERAN/CLAIMANT (Note: You must check at least one box)
AN ATTORNEY IN FACT OR AGENT AUTHORIZED TO ACT ON
BEHALF OF THE VETERAN/CLAIMANT UNDER DURABLE POWER
OF ATTORNEY
A COURT-APPOINTED REPRESENTATIVE
A PERSON WHO IS RESPONSIBLE FOR THE CARE OF THE VETERAN/CLAIMANT,
TO INCLUDE BUT NOT LIMITED TO A SPOUSE OR OTHER RELATIVE
A MANAGER OR PRINCIPAL OFFICER ACTING ON BEHALF OF AN INSTITUTION
WHICH IS RESPONSIBLE FOR THE CARE OF THE VETERAN/CLAIMANT
CHILD
SECTION IV: VETERAN/CLAIMANT INFORMATION
SECTION V: ALTERNATE SIGNER'S DECLARATION OF INTENT
RESPONDENT BURDEN: We need this information to determine entitlement to act as the alternate signer for a veteran/claimant in submitting a claim for
VA benefits (38 U.S.C. 5101). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to
review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control
number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located
on the OMB Internet Page at . If desired, you can call 1-800-827-1000 to get information on where to send comments
or suggestions about this form.
VA FORM 21-0972, OCT 2016
www.reginfo.gov/public.do/PRAMain
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VETERAN'S SSN
18. VETERAN/CLAIMANT IS: (Check ALL that apply)
UNDER 18 YEARS OF AGE
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under
penalty of perjury. I also understand that VA may request further documentation or evidence to verify or confirm
my authorization to sign or complete an application on behalf of the veteran/claimant if necessary. Examples of
evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN);
a certificate or order from a court with competent jurisdiction showing my authority to act for the veteran/
claimant with a judge's signature and date/time stamp; copy of documentation showing appointment of fiduciary;
durable power of attorney showing the name and signature of the veteran/claimant and my authority as attorney
in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person
responsible for the care of the veteran/claimant indicating the capacity or responsibility of care provided; or any
other documentation showing such authorization.
19B. DATE SIGNED (MM,DD,YYYY)
19A. AUTHORIZED SIGNER'S SIGNATURE (Required) (Sign in ink)
PRIVACY ACT NOTICE: 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 38, Code of Federal Regulations 1.576 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 benefits, verification of identity and status, and personnel administration) as identified in the VA system of records,
58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your
obligation to respond is voluntary. 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. The requested information is considered relevant and necessary to determine the
appropriate application and provide it to the veteran/claimant.
MENTALLY INCOMPETENT TO PROVIDE SUBSTANTIALLY ACCURATE INFORMATION NEEDED TO COMPLETE THE CLAIMS FORM, OR TO CERTIFY
THAT STATEMENTS MADE ON THE FORM ARE TRUE AND COMPLETE, OR
PHYSICALLY UNABLE TO SIGN THE CLAIMS FORM
20. REMARKS (If any)
