Form IL 497-0473 Application for Veteran's Compensation by Living Veteran - Illinois

Form IL497-0473 or the "Application For Veteran's Compensation By Living Veteran" is a form issued by the Illinois Department of Veterans Affairs.

The form was last revised in June 1, 2014 and is available for digital filing. Download an up-to-date Form IL497-0473 in PDF-format down below or look it up on the Illinois Department of Veterans Affairs Forms website.

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(CHECK ONE BOX PER APPLICATION)
DVA FILE #
WORLD WAR II
DESERT STORM
_____________________
KOREAN
GLOBAL WAR ON TERRORISM
VIETNAM
STATE OF ILLINOIS
DEPARTMENT OF VETERANS’ AFFAIRS
APPLICATION FOR VETERAN’S COMPENSATION
By Living Veteran
I, ___________________________________________________________________________________________________________
(Last Name)
(First)
(Middle)
(SSN)
(Branch of Service)
(Serial Number)
The name under which I entered the service (if different from above) was__________________________________________________
Present mailing address ________________________________________________________________________________________
(Number)
(Street)
(City or Town)
(County)
(State)
(Zip Code )
do hereby make application for the Illinois Veterans’ Compensation for my service from
_______________________________________, ________ to _____________________________________________, ___________
(Month)
(Day)
(Year)
(Month)
(Day)
(Year)
as evidence by my enclosed copy of Report of Separation (DD Form 214)
I was awarded the
Korean Service Medal
Vietnam Service Medal
Armed Force Expeditionary Medal-Vietnam
Southwest Asia Service Medal
Global War on Terrorism Expeditionary Medal
Global War on Terrorism Service Medal
Afghanistan Campaign Medal
Iraq Campaign Medal
Global War on Terror only: must have served at least 30 consecutive or 60 nonconsecutive days foreign or sea service.
I entered active service from _____________________________________________________ on: ____________________________
(City)
(State)
(Date)
I was separated from active service at _____________________________________________________________________________
(Post, Camp or Station)
My place and date of birth was __________________________________________________________________________________
(City)
(County)
(State)
(Month)
(Day)
(Year)
My type of separation from active service was honorable ______ under honorable conditions______
I was a resident of Illinois for __________ years and __________ months immediately prior to entry into the Armed Forces of the
United States
At time of entry into active service I was residing at _________________________________________________________________
(Number)
(Street)
___________________________________________________________________________________________________________
(City or Town)
(County)
(State)
My address at time of separation from service (Permanent address) was__________________________________________________
(Number)
(Street)
____________________________________________________________________________________________________________
(City or Town)
(County)
(State)
-IMPORTANT NOTICE-
This state agency is requesting disclosure of information necessary to accomplish the statutory purpose of Ch. 122, 30-14.2. Disclosure
IL 497-0473
is REQUIRED: failure to provide this information will prevent the claim from being processed. This form has been approved by the
Revised 06/2014
Forms Management Center.
(CHECK ONE BOX PER APPLICATION)
DVA FILE #
WORLD WAR II
DESERT STORM
_____________________
KOREAN
GLOBAL WAR ON TERRORISM
VIETNAM
STATE OF ILLINOIS
DEPARTMENT OF VETERANS’ AFFAIRS
APPLICATION FOR VETERAN’S COMPENSATION
By Living Veteran
I, ___________________________________________________________________________________________________________
(Last Name)
(First)
(Middle)
(SSN)
(Branch of Service)
(Serial Number)
The name under which I entered the service (if different from above) was__________________________________________________
Present mailing address ________________________________________________________________________________________
(Number)
(Street)
(City or Town)
(County)
(State)
(Zip Code )
do hereby make application for the Illinois Veterans’ Compensation for my service from
_______________________________________, ________ to _____________________________________________, ___________
(Month)
(Day)
(Year)
(Month)
(Day)
(Year)
as evidence by my enclosed copy of Report of Separation (DD Form 214)
I was awarded the
Korean Service Medal
Vietnam Service Medal
Armed Force Expeditionary Medal-Vietnam
Southwest Asia Service Medal
Global War on Terrorism Expeditionary Medal
Global War on Terrorism Service Medal
Afghanistan Campaign Medal
Iraq Campaign Medal
Global War on Terror only: must have served at least 30 consecutive or 60 nonconsecutive days foreign or sea service.
I entered active service from _____________________________________________________ on: ____________________________
(City)
(State)
(Date)
I was separated from active service at _____________________________________________________________________________
(Post, Camp or Station)
My place and date of birth was __________________________________________________________________________________
(City)
(County)
(State)
(Month)
(Day)
(Year)
My type of separation from active service was honorable ______ under honorable conditions______
I was a resident of Illinois for __________ years and __________ months immediately prior to entry into the Armed Forces of the
United States
At time of entry into active service I was residing at _________________________________________________________________
(Number)
(Street)
___________________________________________________________________________________________________________
(City or Town)
(County)
(State)
My address at time of separation from service (Permanent address) was__________________________________________________
(Number)
(Street)
____________________________________________________________________________________________________________
(City or Town)
(County)
(State)
-IMPORTANT NOTICE-
This state agency is requesting disclosure of information necessary to accomplish the statutory purpose of Ch. 122, 30-14.2. Disclosure
IL 497-0473
is REQUIRED: failure to provide this information will prevent the claim from being processed. This form has been approved by the
Revised 06/2014
Forms Management Center.
I have/have not applied for and/or received a bonus or similar payments from another State on account of my service.
If “have’ what State? ___________________________________________________
For World War II Veterans only: Compensation show total active service from September 16, 1940 to September 2, 1945.
ACTIVE DOMESTIC SERVICE (EXCLUDING ALASKA)
ACTIVE FOREIGN SERVICE (INCLUDING ALASKA)
Month’s _____________________ Days ________________
Months ___________________
Days__________________
I hereby certify that statements on page 1 are true and correct to the best of my knowledge and belief
__________________________________________________
(Signature of Applicant)
__________________________________________________
__________________________________________________
(Email)
(Telephone Number)
Do not write below this line
THIS SECTION FOR DVA USE ONLY
DEPARTMENT OF VETERANS’ AFFAIRS
I hereby certify that the within claim has been examined and is hereby certified for payment of $___________ for service in the
Armed Forces of the United States, as provided by the Illinois Veterans’ Compensation Act.
Examined and Verified by: _________________________________
Dated: ___________________________________
(WW II VETERANS ONLY)
ACTIVE DOMESTIC SERVICE
ACTIVE FOREIGN SERVICE
Months of Service ___________________________________
Months of Service ________________________________
Days of Service _____________________________________
Days of Service __________________________________
Amount Due _______________________________________
Amount Due ____________________________________
TOTAL AMOUNT DUE _____________________________
Examined by: _______________________________________________ Date: _______________________________________
APPLICATION PROCEDURE
1. Complete application
2. Submit a copy (ies) of Veteran’s separation or discharge(s).
3. Mail completed application to the Department of Veterans’ Affairs, P.O. Box
19432, 833 South Spring Street, Springfield, Illinois 62794-9432
A separate application must be submitted for each era checked on page 1

Download Form IL 497-0473 Application for Veteran's Compensation by Living Veteran - Illinois

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