VAC 923 Disability Benefits First Application (PEN923e)

Disability Benefits First Application (PEN923e)

Use this form if you are a current or former CAF or RCMP member with a permanent service-related condition, applying to VAC for the first time for this condition. First-time applicants must include proof of identity. Fields marked with an asterisk are required.
Header
Date of application

YearMonthDay
Date
CSDN ID
File No.
Last name
First name
Middle name(s)
Section A — Tell us about yourself
Date of birth

YearMonthDay
Date
Have you ever used any other names during your period of service?
If yes, please specify
Mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City/Town/Village
Country
Province/Territory/State
Postal Code/ZIP
Telephone

Country CodeArea CodePhone Number
Other telephone

Country CodeArea CodePhone Number
Official language for oral communications
Official language for correspondence
Section B — Marital status
Which best describes your marital status?
If you are separated or married/common-law living apart, please explain whether this is due to medical reasons or circumstances beyond your control.
Section C — Spouse/common-law partner
Do you want to provide spouse/common-law partner info?
Spouse/common-law partner (last name, first name)
Other/previous name(s)
Date of birth

YearMonthDay
Date
Date of marriage or date common-law relationship began

YearMonthDay
Date
Has your spouse/common-law partner ever applied for disability or survivor benefits from VAC?
File Number
Spouse Service No.(s)/RCMP Regimental No.(s)
Section D — Dependent children
Do you want to provide dependent children info?
If yes, list each dependent child in the table below.
Provide one row for each dependent child.
You may leave this section blank if you do not have dependent children to report.
Section E — Tell us about your service
Service No.(s) / RCMP Regimental No.(s)
Are you currently serving?
Service history
Have you ever served as a member of the RCMP?
If yes, you must complete a VAC 928 consent form before VAC can request your records.
F — Health condition (complete one set per condition claimed)
Conditions
Conditions
Additional conditions
Section I — Signatures
Declaration agreement
Signature
Date

MonthDayYear
Date
Representative name (print)
Representative telephone

Country CodeArea CodePhone Number
Representative signature
Representative date

YearMonthDay
Date
Should be Empty:

Disability Benefits First Application (PEN923e)

Header

Section A — Tell us about yourself

Section B — Marital status

Section C — Spouse/common-law partner

Section D — Dependent children

Section E — Tell us about your service

F — Health condition (complete one set per condition claimed)

Section I — Signatures