Veterans Questionnaire

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Age
Age
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
How did you hear about us?*
Social Security Number
C-File Number (if known)
Branch of Service*
Date Started Service

MonthDayYear
Date
Date Ended Service

MonthDayYear
Date
Type of Discharge*
Have you previously filed a claim for compensation or pension benefits?*

YesNo
If yes, what was the result?
Do you have a claim currently pending?*

YesNo
What is the date of your last rating decision?

MonthDayYear
Date
What is the date of your last statement of the case?

MonthDayYear
Date
Do you have a decision from the BVA?

YesNo
What is your total current rating?
What is your total current rating?
What are your service connected conditions and their rating?
What conditions do you want to get service connected?*
Are you married?*

YesNo
Name of Spouse

First NameLast Name
Do you have any dependent children?*

YesNo
If so, how many?
Do you have dependent parents?*

YesNo
Where do you get your treatment?
What are the names of the facilities and telephone numbers for where you get treatment?
Are you currently working?*

YesNo
If yes, what is your status?

Full-timePart-time
What is your rate of pay?
What is your current occupation?
If not working, when you did you last work?

MonthDayYear
Date
What was your occupation?
What was your rate of pay?
For how long did this job last?
Why did you stop working?
Have you tried vocational rehabilitation?

YesNo
Do you receive any of the following benefits?

Social Security DisabilitySSIFood Stamps
If yes, then since when?

MonthDayYear
Date
If not receiving any type of Social Security benefits, have you previously applied?

YesNo
Is the claim currently pending?

YesNo
Do you need representation for your Social Security claim?

YesNo
Do you feel like you have recently been harassed by a company who was attempting to collect a debt from you?

YesNo
If you checked “Yes” above, you might be entitled to money damages for harassment and legal representation at no cost to you. We are affiliated with a consumer protection attorney who specializes in suing harassing bill collectors.
Would it be okay if he calls you to see if he can help you with that issue?

YesNo
Please verify that you are human*
Should be Empty: