Benefits Claim Assistance Form
Please fill this out to the best of your knowledge
Veteran's Full Name
*
First Name
Middle Name
Last Name
Last four of Veteran's Social Security Number
*
Last four only please
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Date of Service Start
*
-
Month
-
Day
Year
Date
Date of Service End
*
-
Month
-
Day
Year
Date
Do you have your DD-214 and personal records to include medical?
*
Yes
No
Are you a combat Veteran?
*
Yes
No
Where did you serve?
What are you filing a claim for?
*
Please be as precise as possible.
Have you ever filed a claim before?
*
Yes
No
If yes, who filed the claim?
If yes, what was the claim for?
Do you currently have a VA rating?
*
Yes
No
If yes, what is your current VA rating?
Any additional information you care to provide:
Submit
Should be Empty: