VAC2534 Reassessment Application

CSDN ID

File No.

Last name

First name

Middle name(s)

Salutation

Salutation if Other

Date of birth

Date

Maiden/other previous name(s)

Mailing address

City/Town/Village

Country

Province/Territory/State

Postal Code/ZIP

Telephone

Country CodeArea CodePhone Number

Other telephone

Country CodeArea CodePhone Number

Service No.(s)/RCMP Regimental No.(s)

Which official language do you use in oral communications?

Which official language do you use in correspondence?

Are you an employee of Veterans Affairs?

Has the extent of your permanent and severe impairment(s) for which you have been granted APSC worsened?

If yes, please provide details about any changes to your permanent and severe impairment(s), including how they affect your day-to-day life.

Privacy Notice Veterans Affairs Canada (VAC) takes your privacy seriously. We are committed to protecting your personal information. The information provided on this form is collected under the authority of the Veterans Well-being Act. We will use the information to determine eligibility for and the administration of the Additional Pain and Suffering Compensation. Providing your information is voluntary. However, if you submit an incomplete form there may be delays. This personal information may be shared for case management purposes, to determine your eligibility for additional benefits, or for commemorative activities, where applicable. Your personal information is managed based on the Privacy Act. The Privacy Act provides you with a right of access to your personal information, and to request changes to that personal information if it contains errors. If you are unhappy with how we handle your personal information, you can file a complaint with the Privacy Commissioner of Canada at 30 Victoria Street, Gatineau, QC, K1A 1H3. Additional information about how we handle your personal information is described in VAC's Personal Information Bank, Additional Pain and Suffering Compensation (VAC PPU 716) found on our website, veterans.gc.ca.

I understand it is against the law to knowingly make a false or misleading statement; as legal representative I declare the client to be alive; I agree to notify VAC of any changes affecting eligibility; I have read and understand the Privacy Notice; and I declare the information is true and complete, with the same force and effect as if made under oath.

Signature

Date

Name (please print)

Telephone

Country CodeArea CodePhone Number

Representative signature

Date

Request for APSC Grade Reassessment

Section A — Tell us about yourself

Section B — Tell us about your change of circumstances

Section C — Declaration

Section D — If completing on behalf of the client