VA Form 21-526EZ Application for Disability Compensation and Related Compensation Benefits

VA Form 21-526EZ or the "Application For Disability Compensation And Related Compensation Benefits" is a form issued by the U.S. Department of Veterans Affairs.

The form was last revised in January 1, 2014 and is available for digital filing. Download an up-to-date VA Form 21-526EZ in PDF-format down below or look it up on the U.S. Department of Veterans Affairs Forms website.

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NOTICE TO VETERAN/SERVICE MEMBER
OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR VETERANS DISABILITY
COMPENSATION AND RELATED COMPENSATION BENEFITS
(This notice is applicable to claims for: Disability Service Connection • Secondary Service Connection • Increased Disability
Compensation • Temporary Total Disability Rating • Individual Unemployability • Compensation under 38 U.S.C. 1151 • Special
Monthly Compensation • Specially Adapted Housing/Special Home Adaptation • Automobile Allowance/Adaptive Equipment •
Benefits Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for veterans disability compensation and related compensation benefits.
This notice informs you of the evidence necessary to substantiate your claim. After you submit your claim, you will not receive an initial
letter regarding your claim. You do not need to resubmit another application.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and there
is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans disability compensation or related
compensation benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for
veterans non service-connected pension benefits, use VA Form 21-527EZ, Application for Pension. If you are making a claim for
survivor benefits, use VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits.
VA forms are available at www.va.gov/vaforms.
FDC Criteria (Claim(s) for Veterans Disability Compensation and Related Compensation Benefits)
1. Submit your claim on a signed and completed VA Form 21-526EZ, Application for Disability Compensation and Related
Compensation Benefits (Attached).
2. Submit simultaneously with your claim:
• All, if any, relevant, private medical treatment records; AND
• An identification of any relevant treatment records available at a Federal facility, such as a VA medical center.
Special Circumstances
Under the special circumstances shown below, you must also submit simultaneously with your claim:
• For National Guard and Reserve members, any and all Service Treatment and Personnel Records in
the custody of your Unit(s)
• If claiming dependents, a completed VA Form 21-686c, Declaration of Status of Dependents. If
claiming a child in school between the ages of 18 and 23, you must also submit a completed
VA Form 21-674, Request for Approval of School Attendance. If claiming benefits for a seriously
disabled (helpless) child, you must also submit all, relevant, private medical treatment records
pertaining to the child's pertinent disabilities
• If claiming Post-Traumatic Stress Disorder (PTSD), a completed VA Form 21-0781,
Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder, or if claiming
PTSD based on personal assault, a completed VA Form 21-0781a, Statement in Support of Claim for
Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault
• If claiming Individual Unemployability, a completed VA Form 21-8940, Veteran's Application
for Increased Compensation Based on Unemployability, and a completed VA Form 21-4192, Request
for Employment Information in Connection with Claim for Disability Benefits
• If claiming Specially Adapted Housing or Special Home Adaptation, a completed VA Form
26-4555, Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant
• If claiming Auto Allowance, a completed VA Form 21-4502, Application for Automobile or
Other Conveyance and Adaptive Equipment
• If claiming additional benefits because you or your spouse require Aid and Aid Attendance,
a completed VA Form 21-2680, Examination for Housebound Status or Permanent Need for
Regular Aid and Attendance, or if claiming Aid and Attendance based on nursing home attendance,
a VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid
and Attendance.
3. Report for any VA medical examinations that VA determines are necessary to decide your claim.
VA FORM
SUPERSEDES VA FORM 21-526EZ, AUG 2013,
21-526EZ
Page 1
JAN 2014
WHICH WILL NOT BE USED.
NOTICE TO VETERAN/SERVICE MEMBER
OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR VETERANS DISABILITY
COMPENSATION AND RELATED COMPENSATION BENEFITS
(This notice is applicable to claims for: Disability Service Connection • Secondary Service Connection • Increased Disability
Compensation • Temporary Total Disability Rating • Individual Unemployability • Compensation under 38 U.S.C. 1151 • Special
Monthly Compensation • Specially Adapted Housing/Special Home Adaptation • Automobile Allowance/Adaptive Equipment •
Benefits Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for veterans disability compensation and related compensation benefits.
This notice informs you of the evidence necessary to substantiate your claim. After you submit your claim, you will not receive an initial
letter regarding your claim. You do not need to resubmit another application.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and there
is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans disability compensation or related
compensation benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for
veterans non service-connected pension benefits, use VA Form 21-527EZ, Application for Pension. If you are making a claim for
survivor benefits, use VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits.
VA forms are available at www.va.gov/vaforms.
FDC Criteria (Claim(s) for Veterans Disability Compensation and Related Compensation Benefits)
1. Submit your claim on a signed and completed VA Form 21-526EZ, Application for Disability Compensation and Related
Compensation Benefits (Attached).
2. Submit simultaneously with your claim:
• All, if any, relevant, private medical treatment records; AND
• An identification of any relevant treatment records available at a Federal facility, such as a VA medical center.
Special Circumstances
Under the special circumstances shown below, you must also submit simultaneously with your claim:
• For National Guard and Reserve members, any and all Service Treatment and Personnel Records in
the custody of your Unit(s)
• If claiming dependents, a completed VA Form 21-686c, Declaration of Status of Dependents. If
claiming a child in school between the ages of 18 and 23, you must also submit a completed
VA Form 21-674, Request for Approval of School Attendance. If claiming benefits for a seriously
disabled (helpless) child, you must also submit all, relevant, private medical treatment records
pertaining to the child's pertinent disabilities
• If claiming Post-Traumatic Stress Disorder (PTSD), a completed VA Form 21-0781,
Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder, or if claiming
PTSD based on personal assault, a completed VA Form 21-0781a, Statement in Support of Claim for
Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault
• If claiming Individual Unemployability, a completed VA Form 21-8940, Veteran's Application
for Increased Compensation Based on Unemployability, and a completed VA Form 21-4192, Request
for Employment Information in Connection with Claim for Disability Benefits
• If claiming Specially Adapted Housing or Special Home Adaptation, a completed VA Form
26-4555, Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant
• If claiming Auto Allowance, a completed VA Form 21-4502, Application for Automobile or
Other Conveyance and Adaptive Equipment
• If claiming additional benefits because you or your spouse require Aid and Aid Attendance,
a completed VA Form 21-2680, Examination for Housebound Status or Permanent Need for
Regular Aid and Attendance, or if claiming Aid and Attendance based on nursing home attendance,
a VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid
and Attendance.
3. Report for any VA medical examinations that VA determines are necessary to decide your claim.
VA FORM
SUPERSEDES VA FORM 21-526EZ, AUG 2013,
21-526EZ
Page 1
JAN 2014
WHICH WILL NOT BE USED.
The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!
Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are entitled.
If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your claim, then
VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard Claim Process. See
below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional Expedited Process). If you
wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim Process.
WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide the VA information sufficient to enable it to obtain all relevant
evidence not in your possession. If your claim involves a disability that you had before entering service and that was made worse by
service, please provide any information or evidence in your possession regarding the health condition that existed before your entry
into service.
IMPORTANT: If you are filing your claim prior to or within one year of your separation from the military, please provide a certified
copy of your DD Form 214, "Certificate of Release or Discharge from Active Duty" as early as possible following your separation, as
this may expedite the completion of your claim.
FDC Program (Optional Expedited Process)
Standard Claim Process
You must:
You must:
• Submit your claim in accordance with the "FDC
• If you know of evidence not in your possession and want
Criteria" (see page 1)
VA to try to get it for you, give VA enough information
about the evidence so that we can request it from the
person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure we
receive all requested records that are not in the possession of a
Federal department or agency.
HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
FDC Program (Optional Expedited Process)
Standard Claim Process
VA will:
VA will:
• Retrieve relevant records from a Federal facility, such
• Retrieve relevant records from a Federal facility such as a
as a VA medical center, that you adequately identify
VA medical center, that you adequately identify and
and authorize VA to obtain
authorize VA to obtain
• Provide a medical examination for you, or get a
• Provide a medical examination for you, or get a medical
medical opinion, if we determine it is necessary to
opinion, if we determine it is necessary to decide your claim
decide your claim
• Make every reasonable effort to obtain relevant records
not held by a Federal facility that you adequately identify
and authorize VA to obtain. These may include records
from State or local governments and privately held evidence
and information you tell us about, such as private doctor or
hospital records from current or former employers
WHEN YOU SHOULD SEND WHAT WE NEED
FDC Program (Optional Expedited Process)
Standard Claim Process
You must:
You are strongly encouraged to:
• Send the information and evidence simultaneously with
• Send any information or evidence as soon as you can
your claim
If you submit additional information or evidence after you
You have up to one year from the date we receive the claim to
submit your "fully developed" claim, then VA will remove the
submit the information and evidence necessary to support your
claim from the FDC Program Expedited Process and process
claim. If we decide the claim before one year from the date we
it in the Standard Claim Process. If we decide your claim before
receive the claim, you will still have the remainder of the one year
one year from the date we receive the claim, you will still have
period to submit additional information or evidence necessary to
the remainder of the one-year period to submit additional
support the claim.
information or evidence necessary to support the claim.
WHERE TO SEND INFORMATION AND EVIDENCE
Mail or take your application and any evidence in support of your claim to the closest VA regional office. VA regional office addresses
are available on the Internet at www.va.gov/directory.
Page 2
VA FORM 21-526EZ, JAN 2014
WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
See the evidence table titled...
If you are claiming...
You have a disability that was caused or aggravated by your service
Disability Service Connection
Your service connected disability caused or aggravated an additional
Secondary Service Connection
disability
Your service connected disability has worsened
Increased Disability Compensation
Your service connected disability caused you to be hospitalized or to
Temporary Total Disability Rating
undergo surgery or other treatment
Your service connected disability(ies) prevents you from getting or
Individual Unemployability
keeping substantial employment
You have a disability caused or aggravated by VA medical
Compensation Under 38 U.S.C. 1151
treatment, vocational rehabilitation, or compensated work therapy
Your service connected disability(ies) causes you to be in need of
Special Monthly Compensation
aid and attendance or to be confined to your residence
If you are claiming benefits...
See the evidence table titled...
For adapting and/or purchasing a residence
Special Adapted Housing or Special Home Adaptation
For adapting and/or purchasing a vehicle
Auto Allowance
Because your spouse is severely disabled
Special Monthly Compensation
Because your child is severely disabled
Helpless Child
EVIDENCE TABLES
Disability Service Connection
To support a claim for service connection, the evidence must show:
• You had an injury in service, or a disease that began in or was made permanently worse during service, or there was an event in
service that caused an injury or disease; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and
recurrent symptoms of disability that are visible or observable; AND
• A relationship exists between your current disability and an injury, disease, symptoms, or event in service. This may be shown by
medical records or medical opinions or, in certain cases, by lay evidence. However, under certain circumstances, VA may
presume that certain current disabilities were caused by service, even if there is no specific evidence proving this in your
particular claim. The cause of a disability is presumed for the following veterans who have certain diseases:
• Former prisoners of war;
• Veterans who have certain chronic or tropical diseases that become evident within a specific period of time after discharge
from service;
• Veterans who were exposed to ionizing radiation, mustard gas, or Lewisite while in service;
• Veterans who were exposed to certain herbicides, such as by serving in Vietnam; or
• Veterans who served in the Southwest Asia theater of operations during the Gulf War.
To support a claim for service connection based upon a period of active duty for training, the evidence must show:
• You were disabled during active duty for training due to disease or injury incurred or aggravated in the line of duty; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and
recurrent symptoms of disability that are visible or observable; AND
• There is a relationship between your current disability and the disease or injury incurred or aggravated during active duty for
training. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.
To support a claim for service connection based upon a period of inactive duty training, the evidence must show:
• You were disabled during inactive duty training due to an injury incurred or aggravated in the line of duty or an acute myocardial
infarction, cardiac arrest, or cerebrovascular accident during inactive duty training; AND
• You have a current physical or mental disability. This may be shown by medical evidence or by lay evidence of persistent and
recurrent symptoms of disability that are visible or observable; AND
• There is a relationship between your current disability and your inactive duty training. This may be shown by medical records or
medical opinions or, in certain cases, by lay evidence.
Page 3
VA FORM 21-526EZ, JAN 2014
EVIDENCE TABLES (Continued)
Disability Service Connection (Continued)
In order to reopen a claim previously denied by VA, we need new and material evidence. New and material evidence must raise a
reasonable possibility of substantiating your claim. The evidence cannot simply be repetitive or cumulative of the evidence we had
when we previously decided your claim. VA will make reasonable efforts to help you obtain currently existing evidence. However,
we cannot provide a medical examination or obtain a medical opinion until your claim is successfully reopened.
• To qualify as new, the evidence must currently exist and be submitted to VA for the first time
• In order to be considered material, the additional existing evidence must pertain to the reason your claim was previously denied
Secondary Service Connection
To support a claim for compensation based upon an additional disability that was caused or aggravated by a service-connected
disability, the evidence must show:
• You currently have a physical or mental disability shown by medical evidence or by lay evidence of persistent and recurrent
symptoms of disability that are visible or observable, in addition to your service-connected disability; AND
• Your service-connected disability either caused or aggravated your additional disability. This may be shown by medical records
or medical opinions or, in certain cases, by lay evidence. However, VA may presume service-connection for cardiovascular
disease developing in a claimant with certain service-connected amputation(s) of one or both lower extremities.
Increased Disability Compensation
If VA previously granted service connection for your disability and you are seeking an increased evaluation of your service-
connected disability, we need medical or lay evidence to show a worsening or increase in severity and the effect that worsening or
increase has on your ability to work.
Temporary Total Disability Rating
In order to support a claim for a temporary total disability rating due to hospitalization, the evidence must show:
• You were treated for more than 21 days for a service-connected disability at a VA or other approved hospital; OR
• You underwent hospital observation at VA expense for a service-connected disability for more than 21 days.
In order to support a claim for a temporary total disability rating due to surgical or other treatment performed by a VA or other
approved hospital or outpatient facility, the evidence must show:
• The surgery or treatment was for a service-connected disability; AND
• The surgery required convalescence of at least one month; OR
• The surgery resulted in severe postoperative residuals, such as incompletely healed surgical wounds, stumps
of recent amputations, therapeutic immobilizations, house confinement, or the required use of a wheelchair or crutches; OR
• One major joint or more was immobilized by a cast without surgery.
Individual Unemployability
In order to support a claim for a total disability rating based on individual unemployability, the evidence must show:
• That your service-connected disability or disabilities are sufficient, without regard to other factors, to prevent you from
performing the mental and/or physical tasks required to get or keep substantially gainful employment; AND
• Generally, you meet certain disability percentage requirements as specified in 38 Code of Federal Regulations 4.16 (i.e. one
disability ratable at 60 percent or more, OR more than one disability with one disability ratable at 40 percent or more and a
combined rating of 70 percent or more).
In order to support a claim for an extra-schedular evaluation based on exceptional circumstances, the evidence must show:
• That your service-connected disability or disabilities present such an exceptional or unusual disability picture, due to such factors
as marked interference with employment or frequent periods of hospitalization, that application of the regular schedular standards
is impractical.
Compensation Under 38 U.S.C. 1151
In order to support a claim for compensation under 38 U.S.C. 1151, the evidence must show that, as a result of VA hospitalization,
medical or surgical treatment, examination, or training, you have:
• An additional disability or disabilities; OR
• An aggravation of an existing injury or disease; AND
• The disability was the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment, or not
a reasonably expected result or complication of the VA care or treatment; OR
• The direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy program.
Page 4
VA FORM 21-526EZ, JAN 2014
EVIDENCE TABLES (Continued)
Special Monthly Compensation
In order to support a claim for increased benefits based on the need for aid and attendance, the evidence must show that, due to
your service-connected disability or disabilities:
• You require the aid of another person in order to perform personal functions required in everyday living, such as bathing,
feeding, dressing yourself, attending to the wants of nature, adjusting prosthetic devices, or protecting yourself from the hazards
of your daily environment (38 Code of Federal Regulation 3.352(a)); OR
• You are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed course of
convalescence or treatment (38 Code of Federal Regulation 3.352(a)).
In order to support a claim for increased benefits based on an additional disability or being housebound, the evidence must show:
• You have a single service-connected disability evaluated as 100 percent disabling AND an additional service-connected
disability, or disabilities, evaluated as 60 percent or more disabling; OR
• You have a single service-connected disability evaluated as 100 percent disabling AND, due solely to your service-connected
disability or disabilities, you are permanently and substantially confined to your immediate premises
In order to support a claim for increased benefits based on your spouse's need for aid and attendance, per the provisions of 38
C.F.R. § 3.351(c), the evidence must show:
• Your spouse is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction
of the visual field to 5 degrees or less; OR
• Your spouse is a patient in a nursing home because of mental or physical incapacity; OR
• Your spouse requires the aid of another person in order to perform personal functions required in everyday living, such as
bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the
hazards of his or her daily environment (See 38 C.F.R. § 3.352(a) for complete explanation)
IMPORTANT: For additional benefits to be payable for a spouse, the veteran must be entitled to compensation and evaluated as 30
percent or more disabling.
Specially Adapted Housing or Special Home Adaptation
To support your claim for specially adapted housing (SAH), the evidence must show you are a:
• Veteran entitled to compensation under 38 U.S.C. Chapter 11 for a permanent and totally disabling qualifying condition, OR
• Service member on active duty who has a permanent and totally disabling qualifying condition incurred or aggravated in the line
of duty.
To support that you have a qualifying condition for SAH the evidence must show:
• Amyotrophic lateral sclerosis (ALS), OR
• Loss (amputation) or loss of use of
• both lower extremities, OR
• one lower extremity and one upper extremity affecting balance or propulsion, OR
• one lower extremity plus residuals of organic disease or injury affecting balance or propulsion creating a need for regular,
constant use of a wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other
methods may be occasionally possible); OR
• Loss or loss of use of both upper extremities precluding use of the arms at or above the elbow; OR
• Blindness in both eyes, with light perception only and the loss or loss of use of one lower extremity; OR
• A severe burn injury, meaning full thickness or subdermal burns that have resulted in contractures with limitation of motion of
• two or more extremities; OR
• at least one extremity and the trunk.
To support your claim for SAH the evidence may alternatively show you are a:
• Veteran who served and became permanently disabled from a qualifying condition on or after September 11, 2001, OR
• Service member on active duty who was permanently disabled in the line of duty from a qualifying condition on or after the
same date.
To support that you have a qualifying condition under the alternative service criteria the evidence must show:
• Loss (amputation) or loss of use of
• one or more lower extremities, severely affecting the functions of balance or propulsion and creating a need for regular,
constant use of a wheelchair, braces, crutches or canes as a normal mode of getting around (although getting around by other
methods may be occasionally possible).
Page 5
VA FORM 21-526EZ, JAN 2014
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