GENERAL INSTRUCTIONS (Continued)
What medical evidence should I submit?
If you are you are a veteran who is claiming pension and you are age 65 or older, or determined to be disabled by the Social
Security Administration, you DO NOT have to submit medical evidence with your application unless you are claiming special
monthly pension. Otherwise, provide only those medical records that are related to the disabilities that prevent you from
working.
If you wish to claim special monthly pension and are not in a nursing home, please complete and attach with this application,
VA Form 21-2680, Exam for Housebound Status or Permanent Need for Regular Aid and Attendance. Please make sure
every box is complete and the application is signed by a physician, physician assistant (PA), certified nurse practitioner
(CNP), or clinical nurse specialist (CNS). If you are a patient in a nursing home, please attach a completed VA Form
21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance, signed by an official of
the nursing home showing the date you were admitted to the nursing home, the level of care you receive, and whether
Medicaid covers all or part of your nursing home costs.
If you want help getting medical records related to this claim, you may complete VA Form 21-4142, Authorization and
Consent to Release Information to the Department of Veterans Affairs (VA). By signing VA Form 21-4142, you authorize any
doctors, hospitals, or caregivers that have treated you to release information about your treatment to VA. You do not need to
complete this form for any treatment you received at a VA facility. If you need a copy of the VA Form 21-4142 or VA Form
21-0779, you may contact VA as shown on page 1 in "How can I contact VA if I have a question?" or download the forms
from the VA web site www.va.gov/vaforms.
You may wish to contact an accredited veterans service officer (VSO) to assist you with your application. For a list of
accredited veterans service organizations go to https://www.va.gov/vso/. You may also contact your state office of veterans
affairs at https://www.va.gov/statedva.htm, should you need further assistance with the application process.
Depending on the type of representative you want to designate, please submit one of the following forms:
• VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative or
• VA Form 21-22A, Appointment of Individual as Claimant's Representative
You may download these forms at: www.va.gov/vaforms. If you have already designated a representative, no further action
is required on your part.
What do I do when I have completed my application?
How can I assign someone to act as my representative?
IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or
your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible
for benefits) (38 U.S.C. § 103(c)). Additional guidance on VA recognized marriages is available at https://www.va.gov/opa/marriage/.
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VA FORM 21P-527, AUG 2022
PRIVACY ACT INFORMATION: The form will be used to determine allowance to pension 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 Veteran Readiness 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 response 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 pension. Title 38, United States Code, allows us to ask for this information. We estimate that you will need
an average of 1 hour 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.
When you have completed this application, mail it to the Pension Intake Center listed below. Be sure to attach any materials
that support and explain your claim. Also, make a photocopy of your application and everything that you submit to VA
before mailing it.
Fees for claims: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding
fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the
Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or
agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and
the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.
MAIL: Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, WI 53547-5365