VA Form 21-526C Pre-discharge Compensation Claim

What Is VA Form 21-526C?

VA Form 21-526C, Pre-Discharge Compensation Claim is a form used for filing a pre-discharged claim.

The latest version of the form was released by the Department of Veterans Affairs (VA) in June 2016 with all previous editions obsolete. The most recent version of the VA Form 21-526C fillable version is available to download below or can be found through the VA website.

What Is VA Form 21-526C Used for?

VA Form 21-526C is used by service members on active duty to file a pre-discharge claim for VA benefits in advance. Filing the pre-discharged claims allows the service member to start receiving the VA benefits as soon as possible when they discharge from active duty.

ADVERTISEMENT
OMB Control No. 2900-0743
Respondent Burden: 15 minutes
Expiration Date: 06/30/2019
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
PRE-DISCHARGE COMPENSATION CLAIM
(For use only with Benefits Delivery at Discharge (BDD) or Quick Start Claims)
IMPORTANT: Please read the Privacy Act and Respondent Burden on the back before completing the form.
THIS FORM WILL BE USED FOR (CHECK ONLY ONE)
Benefits Delivery at Discharge (BDD) CLAIMS
Quick Start Claims
SECTION I: TO BE COMPLETED BY SERVICE MEMBER
1. SERVICE MEMBER NAME (Last, first, middle)
2. PLACE OF SEPARATION
3. SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM,DD,YYYY)
5. SEX
MALE
FEMALE
6A. CURRENT ADDRESS
6B. TELEPHONE NUMBERS (Include Area Code)
Daytime
Street address, rural route, or P.O. Box
Apt. number
Evening
City
State
ZIP Code
Country
Cell phone
7A. WORK E-MAIL ADDRESS (If applicable)
7B. PERSONAL E-MAIL ADDRESS (If applicable)
8A. FORWARDING ADDRESS
8B. TELEPHONE NUMBER
9B. ADDRESS OF NEXT OF KIN
9A. NAME AND RELATIONSHIP OF NEXT
9C. TELEPHONE NUMBER
OF KIN
OF NEXT OF KIN
10A. HAVE YOU EVER FILED A CLAIM WITH VA?
10B. VA FILE NUMBER
YES
NO
(If "Yes," provide your file number in Item 10B)
11. WHAT DISABILITIES ARE YOU CLAIMING? SUBMIT ADDITIONAL SUPPORTING STATEMENTS AND INFORMATION CONCERNING YOUR
CLAIMED DISABILITIES ON VA FORM 21-4138, STATEMENT IN SUPPORT OF CLAIM, AVAILABLE AT
www.va.gov/vaforms
IMPORTANT: If claiming dependents, please attach a completed VA Form 21-686c, Declaration of Status of Dependents, available at
www.va.gov/vaforms
SECTION II: SERVICE INFORMATION
12A. DID YOU SERVE UNDER ANOTHER NAME?
12B. PLEASE LIST OTHER NAME(S) YOU SERVED UNDER
(If "Yes," go to Item 12B)
YES
NO
(If "No," go to Item 13A)
13C. ANTICIPATED DATE
13D. DID YOU SERVE IN A
13B. BRANCH OF SERVICE
13A. I ENTERED THIS CURRENT PERIOD OF
OF RELEASE FROM
COMBAT ZONE SINCE
ACTIVE SERVICE ON (MM,DD,YYYY)
ACTIVE DUTY
9-11-2001?
YES
NO
mo
day
yr
14B. DATE OF ACTIVATION (MM,DD,YYYY)
14A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
AUTHORITY OF TITLE 10, U.S.C.?
mo
day
yr
YES
NO
(If "Yes," provide date of activation in Item 14B)
15A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?
15B. WHAT IS THE TELEPHONE
NUMBER OF YOUR CURRENT
UNIT? (Include Area Code)
16A. DO YOU HAVE ADDITIONAL PERIODS OF ACTIVE SERVICE?
16B. I PREVIOUSLY ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
YES
(If "Yes," go to Item 16B)
(If "No," go to Item 17A)
NO
mo
day
yr
VA FORM
21-526c
SUPERSEDES VA FORM 21-526c, JAN 2014,
PAGE 1
JUN 2016
WHICH WILL NOT BE USED.
OMB Control No. 2900-0743
Respondent Burden: 15 minutes
Expiration Date: 06/30/2019
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
PRE-DISCHARGE COMPENSATION CLAIM
(For use only with Benefits Delivery at Discharge (BDD) or Quick Start Claims)
IMPORTANT: Please read the Privacy Act and Respondent Burden on the back before completing the form.
THIS FORM WILL BE USED FOR (CHECK ONLY ONE)
Benefits Delivery at Discharge (BDD) CLAIMS
Quick Start Claims
SECTION I: TO BE COMPLETED BY SERVICE MEMBER
1. SERVICE MEMBER NAME (Last, first, middle)
2. PLACE OF SEPARATION
3. SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM,DD,YYYY)
5. SEX
MALE
FEMALE
6A. CURRENT ADDRESS
6B. TELEPHONE NUMBERS (Include Area Code)
Daytime
Street address, rural route, or P.O. Box
Apt. number
Evening
City
State
ZIP Code
Country
Cell phone
7A. WORK E-MAIL ADDRESS (If applicable)
7B. PERSONAL E-MAIL ADDRESS (If applicable)
8A. FORWARDING ADDRESS
8B. TELEPHONE NUMBER
9B. ADDRESS OF NEXT OF KIN
9A. NAME AND RELATIONSHIP OF NEXT
9C. TELEPHONE NUMBER
OF KIN
OF NEXT OF KIN
10A. HAVE YOU EVER FILED A CLAIM WITH VA?
10B. VA FILE NUMBER
YES
NO
(If "Yes," provide your file number in Item 10B)
11. WHAT DISABILITIES ARE YOU CLAIMING? SUBMIT ADDITIONAL SUPPORTING STATEMENTS AND INFORMATION CONCERNING YOUR
CLAIMED DISABILITIES ON VA FORM 21-4138, STATEMENT IN SUPPORT OF CLAIM, AVAILABLE AT
www.va.gov/vaforms
IMPORTANT: If claiming dependents, please attach a completed VA Form 21-686c, Declaration of Status of Dependents, available at
www.va.gov/vaforms
SECTION II: SERVICE INFORMATION
12A. DID YOU SERVE UNDER ANOTHER NAME?
12B. PLEASE LIST OTHER NAME(S) YOU SERVED UNDER
(If "Yes," go to Item 12B)
YES
NO
(If "No," go to Item 13A)
13C. ANTICIPATED DATE
13D. DID YOU SERVE IN A
13B. BRANCH OF SERVICE
13A. I ENTERED THIS CURRENT PERIOD OF
OF RELEASE FROM
COMBAT ZONE SINCE
ACTIVE SERVICE ON (MM,DD,YYYY)
ACTIVE DUTY
9-11-2001?
YES
NO
mo
day
yr
14B. DATE OF ACTIVATION (MM,DD,YYYY)
14A. ARE YOU CURRENTLY ACTIVATED TO FEDERAL ACTIVE DUTY UNDER THE
AUTHORITY OF TITLE 10, U.S.C.?
mo
day
yr
YES
NO
(If "Yes," provide date of activation in Item 14B)
15A. WHAT IS THE NAME AND ADDRESS OF YOUR RESERVE/NATIONAL GUARD UNIT?
15B. WHAT IS THE TELEPHONE
NUMBER OF YOUR CURRENT
UNIT? (Include Area Code)
16A. DO YOU HAVE ADDITIONAL PERIODS OF ACTIVE SERVICE?
16B. I PREVIOUSLY ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
YES
(If "Yes," go to Item 16B)
(If "No," go to Item 17A)
NO
mo
day
yr
VA FORM
21-526c
SUPERSEDES VA FORM 21-526c, JAN 2014,
PAGE 1
JUN 2016
WHICH WILL NOT BE USED.
SECTION III: MILITARY RETIRED PAY
17A. WILL YOU RECEIVE RETIRED PAY?
17B. TYPE OF RETIRED PAY?
LONGEVITY
DISABILITY
YES
NO
(If "Yes," complete Item 17B)
TDRL
18B. LIST AMOUNT (If known)
18C. LIST TYPE (If known)
18A. WILL YOU RECEIVE ANY TYPE OF SEPARATION/SEVERANCE PAY?
YES
NO
(If "Yes," complete Items 18B and 18C)
IMPORTANT: Unless you check the box in Item 19 below, you are telling us that you are choosing to receive VA compensation instead of military retired pay, if it is
determined you are entitled to both benefits. If you are awarded military retired pay prior to compensation, we will reduce your retired pay by that amount. VA will
notify the Military Retired Pay Center of all benefit changes.
If you receive both military retired pay and VA compensation, some of the amount you get may be recouped by VA, or, in the case of Voluntary Separation Incentive
(VSI), by the Department of Defense.
19.
No, I do not want VA compensation in lieu of military retired pay.
SECTION IV: DIRECT DEPOSIT INFORMATION
The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. Please attach a voided personal
check or deposit slip or provide the information requested below in Items 20, 21 and 22 to enroll in direct deposit. If you do not have a bank account, you must receive
your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard you must apply at
www.usdirectexpress.com
or by telephone at
1-800-333-1795. If you elect not to enroll, you must contact representatives handling waiver requests for the Department of Treasury at 1-888-224-2950. They will
encourage your participation in EFT and address any questions or concerns you may have.
20. ACCOUNT NUMBER (Please check the appropriate box and provide the account number, if applicable)
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT
CHECKING
SAVINGS
WITH A FINANCIAL INSTITUTION OR CERTIFIED
PAYMENT AGENT
21. NAME OF FINANCIAL INSTITUTION (Please provide the name of the
22. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the
bank where you want your direct deposit)
bottom left of your check)
SECTION V: CERTIFICATIONS AND SIGNATURE
I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I authorize any
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, and I waive any privilege which makes the information confidential.
23A. YOUR SIGNATURE (Do NOT print)
23B. DATE SIGNED
SECTION VI: WITNESSES TO SIGNATURE
24A. SIGNATURE OF WITNESS (If claimant signed above using an "X")
24B. PRINTED NAME AND ADDRESS OF WITNESS
25A. SIGNATURE OF WITNESS (If claimant signed above using an "X")
25B. PRINTED NAME AND ADDRESS OF WITNESS
PRIVACY ACT NOTICE: The form will be used to determine allowance to compensation benefits (38 U.S.C. 5101). The responses you submit are considered
confidential (38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under
the Privacy Act, including the routine uses 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. The requested information is considered relevant and necessary to determine maximum benefits
under the law. Information submitted is subject to verification through computer matching programs with other agencies. VA may make a "routine use" disclosure for:
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. Your obligation to respond is required in order to obtain or retain benefits. Information that you furnish may be utilized in computer matching programs
with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by
virtue of your participation in any benefit program administered by the Department of Veterans Affairs. Social Security information: You are required to provide the
Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may
disclose them for purposes stated above.
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 15 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.
VA FORM 21-526c, JUN 2016
PAGE 2

Download VA Form 21-526C Pre-discharge Compensation Claim

1203 times
Rate
4.3(4.3 / 5) 72 votes
ADVERTISEMENT

VA Form 21-526C Instructions

The VA Form 21-526C is distributed without filling guidelines. The instructions for completing the form are provided below.

How to Fill Out VA Form 21-526C?

  1. Choose either Benefits Delivery at Discharge (BDD) Claims or Quick Start Claims.
  2. Section I. Personal information. Provide your name, place of separation, social security number, date of birth, sex, address, telephone number, work and personal email address in the corresponding boxes 1-8b. Provide the name and relationship to the next of kin, as well as their address and telephone number in Boxes 9a-c. If you have ever filed a claim with the VA, provide the VA file number in this section.
  3. Section II. Service information. Mark Box 12a if you have served under another name. The name must be provided in box 12b. Enter the date of entering the current period of active service in box 13a. Enter your branch of service in Box 13b. Provide your anticipated date of release in Box 13c. If you have served in a combat zone since 9/11/2001, mark Box 13d.
  4. If you are currently on active duty under the authority of the title 10, indicate this information in box 14a. Provide the date of activation in box 14b. Enter the name and address of current reserve or national guard unit in Box 15a. Enter your current unit telephone number in Box 15b. If you have any additional periods of active service, indicate this in Box 16a, and provide the date of previous active service in Box 16b.
  5. Section III. Information on military retired pay. If you anticipate receiving a retired pay in the future, indicate this in Box 17a and show the type of the pay in Box 17b. If you expect to receive a separation or service pay, indicate this in Box 18a. Give the amount and the type in Boxes 18b and 18c. If you do not wish to receive the VA compensation in lieu of military retired pay, mark the Box 19.
  6. Section IV. Direct deposit information. Give the account number in box 20. Enter the name of a financial institution in Box 21. Enter the routing or transit number in Box 22.
  7. Section V. Certifications and signature. Sign in Box 23a and date in box 23b.
  8. Section VI. Signature of witnesses. Have the witness sign in Boxes 24a and 25a and date in Boxes 24b and 25b.

VA 21-526C Related Forms

The VA 21-526C belongs to the VA 21-526 forms series. The other forms in the series include:

  1. VA Form 21-526, Veteran's Application for Compensation and/or Pension;
  2. VA Form 21-526B, Veteran's Supplemental Claim for Compensation;
  3. VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits.




Page of 2