"Veterans' Preference Eligibility Form"

Veterans' Preference Eligibility Form is a 4-page legal document that was released by the Congressional Budget Office and used nation-wide.

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VETERANS’ PREFERENCE ELIGIBILITY FORM
(To be completed by applicants for covered positions who self-identify as preference eligible)
PERSON APPLYING FOR PREFERENCE
1. Name (Last, First, Middle)
2. Position for which you are applying at CBO
3. Home address (Street Number, City, State and ZIP Code)
4. Date application submitted to CBO
VETERAN INFORMATION (to be provided by person applying for preference)
5. Veteran’s name (Last, First, Middle) exactly as it appears on Service Records
6. Veteran’s periods of service:
Branch of Service
From
To
The Veterans Employment Opportunities Act of 1998 (VEOA), as made applicable by the Congressional Accountability Act of 1995, as amended (CAA),
authorizes the collection of this information. Individuals who are entitled to a veterans’ preference are invited to voluntarily self-identify. Any information
or documentation submitted by an applicant are solely for use in connection with the obligations and efforts of the Congressional Budget Office (CBO) to
provide veterans’ preference to preference-eligible applicants in accordance with the VEOA. Any information that CBO obtains regarding an applicant’s
status as a disabled veteran and any information regarding an applicant’s disability, including his/her medical condition and history, will be kept
confidential and will be collected, maintained and used in accordance with the Americans with Disabilities Act of 1990. An applicant who declines to self-
identify as a disabled veteran and/or provide information and documentation regarding his/her disabled veteran’s status will not be considered for
veterans’ preference. Applicants may obtain a copy of CBO’s veterans’ preference policy by submitting a written request to careers@cbo.gov.
TYPE OF VETERANS’ PREFERENCE CLAIMED
Instructions: Check the block which indicates the type of preference you are claiming. Answer all questions associated with that block. The
Documentation Required column refers you to page 3 of this form for the documents you must submit to support your application. (Please Note:
Eligibility for veterans’ preference is governed by 5. U.S.C. § 2108, 2108a, and applicable regulations. All conditions are not fully described on this form
because of space restrictions. You should submit this form and supporting documents by email to
VEOA@cbo.gov
or by fax at (202) 225-7539 within
two weeks of submitting your application or by the closing date of the vacancy.
Documentation
Required
(See pages 3 and 4)
Veteran’s Claim for Preference based on non-
8.
----------------------------------------------------------------→
compensable or compensable, service-connected disability;
award of the Purple Heart; or receipt of disability retirement
A and B
benefits or pension public laws administered by the
Department of Veterans Affairs or from a Military Service
Department..
9.
Veteran’s Claim for Preference based on active duty
service (1) during a war, campaign or expedition for which a
campaign badge has been authorized, (2) during the period
----------------------------------------------------------------→
of April 28, 1952 through July 1, 1955, (3) for more than 180
consecutive days, any part of which occurred after January
31, 1955, and before October 15, 1976 (excluding service
A and G
under 10 U.S.C. 12103(d)), (4) from August 2, 1990,
through January 2, 1992, (5) for more than 180 consecutive
days, any part of which occurred during the period
beginning September 11, 2001, and ending on August 10,
2010, the last day of Operation Iraqi Freedom.
10. Preference for active duty service members who meet
one of the conditions in either (8) or (9), above, and who
----------------------------------------------------------------→
expect to be discharged or released from active duty under
A (6)
honorable conditions within 120 days.
Page 1 of 4
VETERANS’ PREFERENCE ELIGIBILITY FORM
(To be completed by applicants for covered positions who self-identify as preference eligible)
PERSON APPLYING FOR PREFERENCE
1. Name (Last, First, Middle)
2. Position for which you are applying at CBO
3. Home address (Street Number, City, State and ZIP Code)
4. Date application submitted to CBO
VETERAN INFORMATION (to be provided by person applying for preference)
5. Veteran’s name (Last, First, Middle) exactly as it appears on Service Records
6. Veteran’s periods of service:
Branch of Service
From
To
The Veterans Employment Opportunities Act of 1998 (VEOA), as made applicable by the Congressional Accountability Act of 1995, as amended (CAA),
authorizes the collection of this information. Individuals who are entitled to a veterans’ preference are invited to voluntarily self-identify. Any information
or documentation submitted by an applicant are solely for use in connection with the obligations and efforts of the Congressional Budget Office (CBO) to
provide veterans’ preference to preference-eligible applicants in accordance with the VEOA. Any information that CBO obtains regarding an applicant’s
status as a disabled veteran and any information regarding an applicant’s disability, including his/her medical condition and history, will be kept
confidential and will be collected, maintained and used in accordance with the Americans with Disabilities Act of 1990. An applicant who declines to self-
identify as a disabled veteran and/or provide information and documentation regarding his/her disabled veteran’s status will not be considered for
veterans’ preference. Applicants may obtain a copy of CBO’s veterans’ preference policy by submitting a written request to careers@cbo.gov.
TYPE OF VETERANS’ PREFERENCE CLAIMED
Instructions: Check the block which indicates the type of preference you are claiming. Answer all questions associated with that block. The
Documentation Required column refers you to page 3 of this form for the documents you must submit to support your application. (Please Note:
Eligibility for veterans’ preference is governed by 5. U.S.C. § 2108, 2108a, and applicable regulations. All conditions are not fully described on this form
because of space restrictions. You should submit this form and supporting documents by email to
VEOA@cbo.gov
or by fax at (202) 225-7539 within
two weeks of submitting your application or by the closing date of the vacancy.
Documentation
Required
(See pages 3 and 4)
Veteran’s Claim for Preference based on non-
8.
----------------------------------------------------------------→
compensable or compensable, service-connected disability;
award of the Purple Heart; or receipt of disability retirement
A and B
benefits or pension public laws administered by the
Department of Veterans Affairs or from a Military Service
Department..
9.
Veteran’s Claim for Preference based on active duty
service (1) during a war, campaign or expedition for which a
campaign badge has been authorized, (2) during the period
----------------------------------------------------------------→
of April 28, 1952 through July 1, 1955, (3) for more than 180
consecutive days, any part of which occurred after January
31, 1955, and before October 15, 1976 (excluding service
A and G
under 10 U.S.C. 12103(d)), (4) from August 2, 1990,
through January 2, 1992, (5) for more than 180 consecutive
days, any part of which occurred during the period
beginning September 11, 2001, and ending on August 10,
2010, the last day of Operation Iraqi Freedom.
10. Preference for active duty service members who meet
one of the conditions in either (8) or (9), above, and who
----------------------------------------------------------------→
expect to be discharged or released from active duty under
A (6)
honorable conditions within 120 days.
Page 1 of 4
11. Preference for a Spouse of a living veteran based on the
(a) Are you presently married to the
Yes No
fact that the veteran, because of a service-connected
veteran?
disability, has been unable to qualify for a Federal or D.C.
Government job or any other position along the lines of the
(If No, you are not eligible for
B and H
veteran’s usual occupation.
preference and should not submit
this form.)
12. Preference for a Widow or Widower of a Veteran.
(a) Were you married to the veteran
Yes No
when he or she died? (If No, you
are not eligible for preference and
should not submit this form.)
A, C, D, and F
(b) Have you remarried since the
(Submit F when
veteran’s death? Do not count
applicable.)
marriages that were annulled.
(If Yes, you are not eligible for
preference and should not submit
this form.)
13. Preference for Mother of a veteran who has a service-
Yes
No
connected disability that is permanent and totally disabling,
(a) Are you married now?
Disabled Veteran
or who is deceased, provided you are or were married to
B, E, and H
the father of the veteran, and
(Submit E when
(b) Are you separated?
--- your husband (either the veteran’s father or your
applicable.)
husband as a result of remarriage) is totally and
(If Yes, do not complete (c), go to
permanently disabled, or
(d).)
--- you are now widowed, divorced or separated from the
(c) If married now, is your husband
veteran’s father and have not remarried, or
totally and permanently disabled?
--- you are widowed or divorced from the veteran’s father
(d) If the veteran is deceased, did
and have remarried, but you are now widowed,
he/she die on active duty?
Deceased Veteran
divorced or separated from the husband of your
A, C, D, and E
remarriage.
(If your answer is No to item 13(c) or
(Submit E when
13(d), you are not eligible for
applicable.)
preference and should not submit this
form.)
I certify that all of the statements made in this application are true, complete and correct to the best of my
Subject to 28 U.S.C.
§101(21)
knowledge and belief and are made in good faith. (A false answer to any question may be grounds for not employing you or for dismissing
you after you begin work, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001)).
This form must be signed by all persons claiming a veterans’ preference
Signature of person claiming preference
Date signed
(Month, Day, Year)
FOR USE BY HUMAN RESOURCES
Name and Title of person who verified veterans’
Date of verification
ONLY
preference
(Month, Day, Year)
 Preference entitlement was verified
Page 2 of 4
DOCUMENTATION REQUIRED – READ CAREFULLY
Unless a certified copy is specified, please submit photocopies of documents because they will not be returned.
A. Documentation of Service and Separation under
4) An official statement or retirement orders from a
Honorable Conditions
branch of the Armed Forces showing that the retired
serviceman was retired because of permanent,
Submit any of the documents listed below as
service-connected disability or was transferred to the
documentation, provided they are dated on or after the day
permanent disability retirement list.
of separation from active duty military service:
For spouses and mothers of disabled veterans who
1. Honorable or general discharge certificate.
checked item 10 or 12, submit the following:
2. Certificate of transfer to Navy Fleet Reserve, Marine
Corps Fleet Reserve, or enlisted Reserve Corps.
An official statement, dated 1991 or later, from the
3. Orders of transfer to retired list.
Department of Veterans Affairs or from a branch of the
4. Report of separation from a branch of the Armed
Armed Forces, certifying:
Forces.
5. Certificate of service or release from active duty,
1) the present existence of the veteran’s service-
provided honorable separation is shown.
connected disability,
6. Official statement from a branch of the Armed Forces
2) the percentage and nature of the service-connected
showing that honorable separation took place, or will
disability or disabilities (including the combined
take place within 120 days of certification by
percentage),
appropriate official of the Armed Forces.
3) a notation as to whether the service-connected
7. Notation by the Department of Veterans Affairs or a
disability is rated as permanent and total.
branch of the Armed Forces on an official statement,
Please Note: When a veteran dies on active duty, the family
described in B below, that the veteran was honorably
does not receive a DD Form 214; the family receives a DD
separated from military service.
Form 1300, Report of Casualty, on which there is no place to
8. Official statement from the Military personnel records
record the character of service. Thus, when a veteran dies on
center that official service records show that honorable
active duty, his or her service should be presumed to be
separation took place.
under honorable conditions unless the military service
B. Documentation of Service-Connected Disability;
specifically indicates otherwise.
Purple Heart; and Non-service-Connected Disability
C. Documentation of Veteran’s Death
Pension.
1. If on active military duty at time of death, submit
Submit one of the documents:
official notice, from a branch of the Armed Forces, of
1. An official statement, dated 1991 or later; from the
death occurring under honorable conditions.
Department of Veterans Affairs or from a branch of the
2. If death occurred while not on active duty, submit
Armed Forces, certifying to the present existence of
certified copy of death certificate.
the veteran’s service-connected disability.
D. Documentation of Service or Death During a War, in a
2. An official citation, document or discharge certificate,
Campaign or Expedition for which a Campaign Badge
issued by a branch of the Armed Forces, showing the
is Authorized, or During the Period Authorized, or
award to the veteran of the Purple Heart for wound or
During the Period of April 28, 1952, through July 1,
injuries received in action.
1955.
3. An official statement, dated 1991 or later; from the
Department of Veterans Affairs, certifying that the
Submit documentation of service or death during a war or
veteran is receiving a non-service-connected disability
during the period April 28, 1952, through July 1, 1955, or
pension, compensation for a service-connected
during a campaign or expedition for which a campaign
disability or disability retired pay.
badge is authorized.
Page 3 of 4
E. Documentation of Deceased or Disabled Veteran’s
Section 9.
Mother’s Claim for Preference because of Her
Husband’s Total and Permanent Disability.
Note: A campaign medal holder or Gulf War veteran who
originally enlisted after Sep 7, 1980, (or began active duty
Submit a statement from husband’s physician showing the
on or after 14 October 1982, and has not previously
prognosis of his disease and percentage of his disability.
completed 24 months of continuous active duty) must
submit documentation establishing 24 months of
F. Documentation of Annulment of Remarriage by Widow
continuous service or service for the full period for which
or Widower of Veteran.
called or ordered to active duty. The 24-month service
Submit either:
requirement does not apply to those who are preference
eligible separated for disability incurred or aggravated in
1. Certificate from the Department of Veterans Affairs
the line of duty, or to veterans separated for hardship or
that entitlement to pension or compensation was
other reasons under 10 U.S.C. 1171 or 1173.
restored due to annulment.
2. A certified copy of the court decree of annulment.
H. Documentation of Veteran’s Inability to Work
Because of a Service-Connected Disability
G. Documentation of Service During a War or Certain
Periods of Time.
Answer questions 1-7 below:
Submit a DD-214 or other documentation that establishes
entitlement to a preference described in
H. Documentation of Veteran’s Inability to Work Because of a Service-Connected Disability
1.
Is the veteran currently working?
Yes
No
2. If currently working, what is the veteran’s present occupation?
If No, go to Item 3.
3. What was the veteran’s occupation, if any, before military service?
4. What was the veteran’s military occupation at the time of separation?
5. Has the veteran been employed, or is he/she now employed, by the Federal civil service or D.C. Government?
Yes
No
A. Title and Grade of position, most recently or
B. Name and address of agency
C. Dates of Employment
currently held
From:
To:
6.
Has the veteran resigned from, been disqualified for, or separated from a position in the Federal civil service or D.C. Government along the lines of
his/her usual occupation because of service-connected disability?
Yes
No
If Yes, submit documentation of the resignation, disqualification, or separation.
7.
Is the veteran receiving a civil service retirement pension?
Yes
No
CSA #
If Yes, give the Civil Service annuity or Federal employee retirement annuity number.
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