Fillable Printable Vba 21 8940 Are
Fillable Printable Vba 21 8940 Are
Vba 21 8940 Are
FROM
13. DATE(S) OF HOSPITALIZATION
SECTION III - EMPLOYMENT STATEMENT
NOTE: This is a claim for compensation benefits based on unemployability. When you complete this form you are claiming
total disability because of a service-connected disability(ies) which has/have prevented you from securing or following any
substantially gainful occupation. Answer all questions fully and accurately. See mail/fax information on page 3 of this form.
SECTION II - DISABILITY AND MEDICAL TREATMENT
VETERAN'S APPLICATION FOR INCREASED
COMPENSATION BASED ON UNEMPLOYABILITY
OMB Approved No. 2900-0404
Respondent Burden: 45 minutes
Expiration Date:10/31/2020
Social Security Benefits: Individuals who have a disability and meet medical criteria may qualify for Social Security of Supplemental
Security Income disability benefits. If you would like more information about Social Security benefits, contact your nearest Social
Security Administration (SSA) office. You can locate the address of the nearest SSA office in your telephone book blue pages under
"United States Government, Social Security Administration" or call 1-800-772-1213 (Hearing Impaired TDD line 1-800-325-0778.).
You may also contact SSA by Internet at //www.ssa.gov/.
17A. WHAT IS THE MOST YOU EVER EARNED IN ONE YEAR?
$
VA FORM
OCT 2017
21-8940
SUPERSEDES VA FORM 21-8940, FEB 2016,
WHICH WILL NOT BE USED.
Page 1
14. DATE YOUR DISABILITY AFFECTED
FULL-TIME EMPLOYMENT
15. DATE YOU LAST WORKED FULL-TIME
16. DATE YOU BECAME TOO DISABLED TO WORK
1. NAME OF VETERAN (FIRST, MIDDLE INITIAL, LAST)
17B. WHAT YEAR?17C. OCCUPATION DURING THAT YEAR
3. VA FILE NUMBER
2. VETERAN'S SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM,DD,YYYY)
6. EMAIL ADDRESS
(If applicable)
5. MAILING ADDRESS OF VETERAN (No. and street or rural route, city or P.O., State, ZIP Code and Country)
11. NAME AND ADDRESS OF DOCTOR(S)
12. NAME AND ADDRESS OF HOSPITAL
10. DATE(S) OF TREATMENT BY DOCTOR(S)
9. HAVE YOU BEEN UNDER A DOCTOR'S CARE
AND/OR HOSPITALIZED WITHIN THE PAST 12
MONTHS?
YESNO
8. WHAT SERVICE-CONNECTED DISABILITY PREVENTS
YOU FROM SECURING OR FOLLOWING ANY
SUBSTANTIALLY GAINFUL OCCUPATION?
FROMTO
TO
Month
Month
DayYear
Year
Day
MonthDayYear
YearDayMonth
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
Year
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)
SECTION I - VETERAN IDENTIFICATION INFORMATION
NOTE: You caneither complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly to expedite processing the form.
7. TELEPHONE NUMBER (Include Area Code)
VA FORM 21-8940, OCT 2017
Page 2
VETERAN'S SOCIAL SECURITY NO.
SECTION III - EMPLOYMENT STATEMENT (Continued)
A. NAME AND ADDRESS OF EMPLOYER
(OR UNIT)
B. TYPE OF
WORK
C. HOURS
PER WEEK
F. HIGHEST GROSS
EARNINGS PER MONTH
E. TIME LOST
FROM ILLNESS
D. DATES OF EMPLOYMENT
18H. INDICATE YOUR TOTAL EARNED INCOME FOR THE PAST 12 MONTHS
18I. IF PRESENTLY EMPLOYED, INDICATE YOUR CURRENT MONTHLY EARNED
INCOME
$
$
19. DID YOU LEAVE YOUR LAST JOB/SELF-EMPLOYMENT
BECAUSE OF YOUR DISABILITY?
20. DO YOU RECEIVE/EXPECT TO RECEIVE
DISABILITY RETIREMENT BENEFITS?
21. DO YOU RECEIVE/EXPECT TO RECEIVE
WORKERS COMPENSATION BENEFITS?
(If "Yes," give the facts in Item 26,
"Remarks")
18G. IF YOU ARE CURRENTLY SERVING IN THE RESERVE OR NATIONAL GUARD, DOES YOUR SERVICE CONNECTED DISABILITY PREVENT YOU FROM
PERFORMING YOUR MILITARY DUTIES?
YESNO
YESNO
YES
NO
YESNO
FROMTO
18. LIST ALL YOUR EMPLOYMENT INCLUDING SELF-EMPLOYMENT FOR THE LAST FIVE YEARS YOU WORKED
(Include any military duty including inactive duty for training)
A. NAME AND ADDRESS OF EMPLOYERB. TYPE OF WORK
22. HAVE YOU TRIED TO OBTAIN EMPLOYMENT SINCE YOU BECAME TOO DISABLED TO WORK?
(If "Yes," complete Items 22A, 22B, and 22C)
YESNO
C. DATE APPLIED
25C. DATES OF TRAINING
23. EDUCATION (Check highest year completed)
GRADE SCHOOLHIGH SCHOOLCOLLEGE12 3456784 3
2
14 321
24A. DID YOU HAVE ANY OTHER EDUCATION AND TRAINING BEFORE YOU WERE TOO DISABLED TO WORK?
(If "Yes," complete Items 24B, and 24C)
24B. TYPE OF EDUCATION OR TRAINING
24C. DATES OF TRAINING
25B. TYPE OF EDUCATION OR TRAINING
25A. HAVE YOU HAD ANY EDUCATION AND TRAINING SINCE YOU BECAME TOO DISABLED TO WORK?
(If "Yes," complete Items 25B, and 25C)
YESNO
BEGINNING
COMPLETION
YESNO
BEGINNINGCOMPLETION
SECTION IV - SCHOOLING AND OTHER TRAINING
SECTION IV - AUTHORIZATION, CERTIFICATION, AND SIGNATURE
26. REMARKS (If any)
AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the person or entity, including but not limited to any organization, service provider, employer, or
Government agency, to give the Department of Veterans Affairs any information about me except protected health information, and I waive any privilege which makes the
information confidential.
CERTIFICATION OF STATEMENTS: I CERTIFY THATas a result of my service-connected disabilities, I am unable to secure or follow anysubstantially gainful
occupation and that the statements in this application are true and complete to the best of my knowledge and belief. I understand that these statements will be considered in
determining my eligibility for VA benefits based on unemployability because of service-connected disability.
I UNDERSTAND THAT IF I AM GRANTED SERVICE-CONNECTED TOTAL DISABILITY BENEFITS BASED ON MY UNEMPLOYABILITY, I MUST IMMEDIATELY INFORM
VA IF I RETURN TO WORK. I ALSO UNDERSTAND THAT TOTAL DISABILITY BENEFITS PAID TO ME AFTER I BEGIN WORK MAY BE CONSIDERED AN
OVERPAYMENT REQUIRING REPAYMENT TO VA.
27. SIGNATURE OF CLAIMANT (Do Not Print) (Sign in ink)
WITNESS TO SIGNATURE OF CLAIMANT IF MADE "X" MARK. NOTE: Signature made by mark must be witnessed by two persons to whom the person making the
statement is personally know and the signature and address of such witnesses must be shown below.
29A. SIGNATURE OF WITNESS (Sign in ink)
29B. ADDRESS OF WITNESS
30A. SIGNATURE OF WITNESS (Sign in ink)
30B. ADDRESS OF WITNESS
PENALTY: The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact, knowing it to
be false or for the fraudulent acceptance of any payment to which you are not entitled.
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
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 VA 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 required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under
Title 38, U.S.C. 5101(c)(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a 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 maximum benefits provided under the law. The responses you submit are
considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
VA FORM 21-8940, OCT 2017
Page 3
28. DATE SIGNED
VETERAN'S SOCIAL SECURITY NO.
RESPONDENT BURDEN: We need this information to determine your eligibility for compensation. Title 38, United States Code, allows us to ask for this information. We estimate that you
will need an average of 45 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.
SECTION V - WHERE TO SEND CORRESPONDENCE
MAIL TO:
FAX TO:
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
844-531-7818 (Toll Free) OR
Local: 248-524-4260
