Veterans Benefits Practice Center

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

Are you a veteran of the US military services?

If yes, please answer inquiries about the veteran in question with information about yourself.

Are you a spouse, dependent or survivor of a veteran?
Yes No

If yes, what is or was your relationship with the veteran?

Please provide names of all dependents of the veteran, military branch, rank and dates of service.

If the veteran is deceased, please provide the date and cause of death; state whether the cause was service related; and describe the surrounding circumstances.

Please provide the veteran's date and place of birth.

Was the veteran's discharge honorable?
Yes No

Have you applied for any type of federal or state veterans' benefits?
Yes No

If yes, please provide the type of benefit(s), relevant agency, date(s) of application, whether benefits were granted or denied and the date of the agency decision on the application.

If benefits were denied, has there been any request made for review, reconsideration or appeal, or has a Notice of Disagreement (NOD) been submitted?
Yes No

If yes, please provide details.

Do the benefits applied for concern a medical condition or disability?
Yes No

If yes, what is or was the condition(s) and is or was it service connected? Please provide dates of onset and duration, symptoms and the names of all treating doctors.

Does or did the veteran suffer from any mental or emotional impairment?
Yes No

If yes, please provide diagnosis and relevant dates, describe symptoms and indicate whether it was service connected.

Please provide any additional relevant information about your veterans' benefit claim.

Please share any special concerns about your veterans' benefit claim.