Form 1 Benefits Claims Assistance Disclosure Form - Utah

Form 1 is a Utah Department of Veterans and Military Affairs form also known as the "Benefits Claims Assistance Disclosure Form". The latest edition of the form was released in May 1, 2015 and is available for digital filing.

Download a PDF version of the Form 1 down below or find it on Utah Department of Veterans and Military Affairs Forms website.

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State of Utah VA Benefits Claims Assistance Disclosure Form
The Utah Department of Veterans and Military Affairs provides information and claims preparation
assistance at no charge.
Veterans are welcome to call the department at 801-326-2372.
Veterans submitting claims for VA benefits have rights and protections enumerated in Title 38 Veterans’
Benefits C.F.R (Code of Federal Regulations). These regulations govern individuals providing VA claims
assistance to ensure veterans have responsible, qualified representation in the preparation, presentation, and
prosecution of claims for veterans’ benefits.
Relevant and important provisions of Title 38 include, but are not limited to:
1. Any individual providing VA benefits claims assistance must be accredited by the VA.
2. Federal law restricts charging a veteran, or a member of the veteran’s family, a fee for assisting in the
initial application for VA benefits.
In accordance with Utah Code §71-13-103, the named VA Accredited Claim Representative affirms that:
1. There is no charge to the claimant or a member of the claimant’s family for assistance with the initial
benefits application, and
2. If, as a result of providing assistance for a claim, income is accrued from the sale of a product or other
service to the claimant, the income is both justified and reasonable as compared with income from
similar products and services available in the state.
Name of VA Accredited Claim Representative ____________________________________________
Business address ___________________________________________________________________
Business phone number _____________________________________________________________
VA Accreditation Number ____________________________________________________________
Name of Veteran Claimant ___________________________________________________________
Claimant Address ___________________________________________________________________
Claimant Phone Number _____________________________________________________________
Claim Representative Signature _______________________________________________________
Veteran Claimant/Authorized Representative Signature ____________________________________
Date:_________________________
Pursuant to Utah Code§71-13-103, no provision of this form may be struck out or designated as N/A. A copy of this
completed form shall be provided to the veteran on the day it is signed. Additionally, the Claims Representative must
send a signed copy to the UDVMA within 5 working days (550 Foothill Blvd, Ste 105, Salt Lake City, UT 84113 or
veterans@utah.gov) and retained on file for 3 years.
UDVMA Form 1
May 2015
State of Utah VA Benefits Claims Assistance Disclosure Form
The Utah Department of Veterans and Military Affairs provides information and claims preparation
assistance at no charge.
Veterans are welcome to call the department at 801-326-2372.
Veterans submitting claims for VA benefits have rights and protections enumerated in Title 38 Veterans’
Benefits C.F.R (Code of Federal Regulations). These regulations govern individuals providing VA claims
assistance to ensure veterans have responsible, qualified representation in the preparation, presentation, and
prosecution of claims for veterans’ benefits.
Relevant and important provisions of Title 38 include, but are not limited to:
1. Any individual providing VA benefits claims assistance must be accredited by the VA.
2. Federal law restricts charging a veteran, or a member of the veteran’s family, a fee for assisting in the
initial application for VA benefits.
In accordance with Utah Code §71-13-103, the named VA Accredited Claim Representative affirms that:
1. There is no charge to the claimant or a member of the claimant’s family for assistance with the initial
benefits application, and
2. If, as a result of providing assistance for a claim, income is accrued from the sale of a product or other
service to the claimant, the income is both justified and reasonable as compared with income from
similar products and services available in the state.
Name of VA Accredited Claim Representative ____________________________________________
Business address ___________________________________________________________________
Business phone number _____________________________________________________________
VA Accreditation Number ____________________________________________________________
Name of Veteran Claimant ___________________________________________________________
Claimant Address ___________________________________________________________________
Claimant Phone Number _____________________________________________________________
Claim Representative Signature _______________________________________________________
Veteran Claimant/Authorized Representative Signature ____________________________________
Date:_________________________
Pursuant to Utah Code§71-13-103, no provision of this form may be struck out or designated as N/A. A copy of this
completed form shall be provided to the veteran on the day it is signed. Additionally, the Claims Representative must
send a signed copy to the UDVMA within 5 working days (550 Foothill Blvd, Ste 105, Salt Lake City, UT 84113 or
veterans@utah.gov) and retained on file for 3 years.
UDVMA Form 1
May 2015

Download Form 1 Benefits Claims Assistance Disclosure Form - Utah

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