TXD V400.6 P191 TEXAS VETERAN S COMMISSION P A M P H L

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1 TXD V400.6 P191 TEXAS VETERAN COMMISSION S P A M P H L E T May/June 2009 A MOST COMMONLY USED S (VA, TVC, DoD) NIVERSITY OF TAN -INBURG, TEAM 7b '3c U Cd -J t4 rcq 1 LJLPUxAT&y U5RAFY NO The Texas Veterans Commission does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or providing services. TH IVER1T OF4 TEXS 67N MICAN

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3 FOREWORD We have shown on the following pages the number, title and latest known revision date of numerous VA and other miscellaneous forms. In some instances, the revision date may be incorrect, since the form may have been revised since work commenced on this pamphlet. The information contained in this pamphlet will be reviewed periodically and revised. We hope that you will find the infonnation in this pamphlet helpful in setting up your forms supply. In the event you need assistance concerning any fonn, please remember that you can contact the Publications Unit of the VA Regional Office serving your area. Also keep in mind that the representatives of the Texas Veterans Commission and the service organization departments located in VA Regional Offices stand ready to assist you in every way possible in maintaining a supply of current forms. In order to do your job efficiently and to provide your veterans with the very best service, it is absolutely necessary that you maintain a supply of proper forms. Using VA Form , Request for VA Fonns and Publications, directed to the Publication Clerk, VA Regional Office, Houston or Waco, Texas, Service Officers may procure necessary supplies of forms. Forms can also be downloaded via the Internet at the VA's website at Note that those listed with an asterisk (*) are not stocked by VA Publications. A special thanks to Jerry Goode, Regional Director and Sandra Covin, Veterans Counselor, TVC Claims Representation and Counseling Program at the Waco Regional Office; and Rufus Coburn, Manager and Terry O'Neill, Program Specialist for TVC Veterans Education Program in Austin, for their assistance in compiling the information in this Pamphlet. TBEOF CONTENTS Miscellaneous Forms... Page 1 Educational & Vocational Rehab Forms... Page 1 Finance & Budget Form s... Page 2 Governm ent Insurance Form s... Page 2 L oan G uaranty Form s... Page 3 Medical Forms... Page 4 Veterans Service Center Forms...Page 4 Department of Defense Forms...Page 6 TVC Forms... Page 7 * TVC Pamphkei, May/lune 2009 Page Commonly Used Forms (VA, DoD, TVC)

4 Various divisions, such as the Adjudication, Administrative, etc., handle the U.S. Department of Veterans Affairs (VA) operations. A prefix number on VA forms distinguishes each operating division. Some forms, however, can be classified only as miscellaneous since they are processed through more than one operating division. The most commonly known of these miscellaneous forms are listed below: NUMBER VA-8 VA-9 VA-3288 VA TITLE IREVISION DATE Certification of Appeal 06/08 Appeal to Board of Veterans' Appeals 06/08 Request for and Consent to Release 10/95 Information from Claimant's Records Application for Standard Government 05/08 Headstone or Marker for Installation In a Private Cemetery or a State Veterans' Cemetery Financial Status Report 06/09 Application for 10 point Veterans Preference 12/04 Request Pertaining to Military Records 09/08 11/08 11/08 VA 5655 SF-15 SF a CHAMPVA Claim Form c CHAMPVA-Other Health Insurance (OHI) Certificate Request for VA Forms and Publications EDUCATIONAL& VOCI[ONA R ta 01/01 The entire educational assistance program of the U.S. Department of Veterans Affairs is now handled through the Adjudication Division by the same VA personnel that process disability and death benefit claims. In order to distinguish between the forms which are used for compensation and pension and the educational assistance programs, VA forms for the latter are designated with the prefix "22". VA currently operates programs providing educational assistance to disabled veterans, to non-disabled veterans, to reservists, war orphans, and to the children of veterans who are totally disabled because of service-connected disabilities. Following is a listing of VA forms that are most widely used in the educational assistance programs administered by the U.S. Department of Veterans Affairs. NUMBER TITLE Application for Education Benefits (Under Chapter 30, 32, 33, Title 38; Chapter 1606 and 1607, Title 10) REVISION DATE 05/09 TVC PamphletMay'June 2009 Commonly Used Forms (PA, DoD, TV,) Page 1

5 Request for Change of Program or 11/08 Place of Training Application for Survivors' and Dependents 01/09 Educational Assistance Request for Change of Program or Place 02/07 of Training Survivors' and Dependents Educational Assistance c Monthly Certification of Flight Training 07/ Student Work-Study Agreement 11/05 (Student Services) Supplemental Information for Change of 09/06 Program or Reenrollment After Unsatisfactory Attendance, Conduct or Progress Application for Educational Assistance 04/01 Test Program Benefits Application for Refund of Educational 07/07 Contributions (VEAP, Chapter 32, Title 38) Disabled Veterans Application for 02/08 Vocational Rehabilitation (Chapter 31, Title 38) FINANCE & BUDGET S The following forms are used for financial transactions with various VA programs. Some of the forms are used to serve the same purpose for different programs (i.e., can be used for Disability and GI Bill enrollment.) NUMBER TITLE REVISION DATE Direct Deposit Enrollment 02/ Request for Change of Address/Cancellation 03/96 of Direct Deposit VA-5655 Financial Status Report 06/09 GOVERNMENT INSURANCE S Following is a listing of the various VA forms to be used in connection with all types of Government Insurance, including National Service Life Insurance, United States Government Life Insurance, Service Disabled Insurance, Veterans' Special Life Insurance, etc.: NUMBER TITLE REVISION DATE Designation of Beneficiary- 12/05 Government Life Insurance * TVC Pamphlet, May/June 2009 Page 2 Commonly Used Forms (VA, Ioi), TVC)

6 SGL- 180 SGLV-8283 SGLV-8283A SGLV-8600 SGLV-8714 SGLV-8721 SGL Brochure Claim for Disability Insurance Benefits Application for Conversion Claim for One Sum Payment Direct Deposit Enrollment/Change Application for Reinstatement of Coverage (VGLI) Claim for Death Benefits (SGLI/VGLI) Claim for Family Coverage Death Benefits (SGLI) Traumatic Injury Protection Certification Form Application for VGLI Beneficiary Designation Form (VGLI) Information Pamphlet for Converting SGLI to VGLI Participating Companies Brochure (Contains list of commercial insurance companies that will accept a SGLI, FSGLI or VGLI conversion) 04/05 10/06 03/08 08/06 11/08 09/07 09/07 04/09 10/08 02/08 11/05 07/08 LNGUARANTYFr The Service Officers in the field are required to stock only a few forms pertaining to the Loan Guaranty Program administered by VA. In most instances, any forms that must be completed by the veteran, widow, a lender, etc., are mailed directly by the Loan Guaranty Division to the party involved for completion and return. There are only eight (8) basic forms, which Service Officers should keep in stock at all times. NUMBER TITLE RREVISION DATE Request for Determination of Loan Guaranty Eligibility - Unmarried Surviving Spouses 11/ Request for Certificate of Eligibility 04/ Veterans Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant 10/ c Veterans Supplemental Application for Assistance in Acquiring Specially Adapted Housing 04/ d Veterans Application for Assistance in Acquiring Special Housing Adaptations 06/ Application for Assumption Approval and/or Release from Personal Liability to the Government on a Home Loan 01/ Statement of Purchaser or Owner Assuming Seller's Loan 05/ a Request for Certificate of Veteran Status (HUD/FHA) 09/04 * TVC Pamphlet, May'June 2009 Commonly Used Forms (VA, DoD, TV) Page 3

7 8..."3 333 " Zi 3S:" "o3s3 ",?3.s'C:.3 5?i3Y?:>45?Sx'?.?F3i3.'.s"' a^:"c-i ' 3F.i'".a ".. 5".iZ C\".,'i! ""Si. f'r , t..>,,...3i:'3.., ;3 d' f c3?f.:3 3 4?At : k... t;4?i k :3^.Si s:,x.*ayrr 33Sv ',3?.2*M. IVr. Y?3?Si?3 t The following is a list of the various VA forms that are used for purposes involving medical treatment, hospitalization, drugs and medicines, etc., or any other type of benefit under the medical programs operated by VA through medical centers, Regional Offices, and outpatient clinics: NUMBER TITLE EC Application for Extended Care Services EZ Application for Health Benefits EZR Health Benefits Renewal W r10 d Application for CHAMPVA Benefits m Medical Certificate SH State Home Program Application for Veterans Care medical Certificate Meds by Mail Order Form (CHAMPVA) Claim for Payment of Cost of Unauthorized Medical Services Request for and Authorization to Release Medical Records c CHAMPVA - Other Health Insurance (OHI) Certification d CHAMPVA Potential Liability Claim Application for Annual Clothing Allowance REVISION DATE 05/05 07/08 07/08 06/05 06/03 04/09 08/08 06/07 05/05 11/08 03/04 03/06 VE 'ian SES ENE OM The Veterans Service Center of a VA Regional Office is responsible for receiving and processing all types of claims for disability and death benefits, both service connected and nonservice-connected. Such action includes the initial claims, reopened claims, claims for increase, appeals, reevaluations, etc. Any claim that is made for disability or death benefits by a veteran, his/her dependents or survivors, is received by the Veterans Service Center where the claim is developed and a determination is made concerning the eligibility of the claimant to monetary benefits. Also included as duties of the particular division are payment of VA burial allowance claims, as well as claims for accrued amounts, reimbursement amounts and certain phases of the payment of Government Life Insurance claims following the death of an insured veteran. The following list includes some VA forms commonly used by the Veterans Service Center: NUMBER TITLE PREVISION DATE Application for U.S. Flag for Burial Purposes 09/05 Appointment of Veterans Service 11/05 Organization as Claimant's Representative C. npamphled, May 2009 Dne Commonly Used Farms (1/A, IDaD, TG'(C) Page -4

8 21-22a Appointment of Individual 05/07 as Claimant's Representative Veteran's Application for 01/04 Compensation and Pension Income-Net Worth & Employment Statement 06/ Application for Burial Benefits 06/02 Under 38 USC Chapter a State Application for Interment Allowance 08/05 Under 38 USC Chapter Application for Dependency and Indemnity 06/05 Compensation, Death Pension & Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation) a Application for Dependency and Indemnity 03/04 Compensation by a Surviving Spouse or Child (In-service death only) Application for Dependency and Indemnity 04/05 Compensation by Parents Application for Accrued Amounts Due 05/05 a Deceased Beneficiary Request for Approval of School Attendance 09/ c Declaration of Status of Dependents 11/ Application for Benefits for Certain Children 09/06 with Disabilities Born of Vietnam and Certain Korea Service Veterans Veterans Benefits Timetable 05/ Eligibility Verification Report Instructions 06/ V-1 Old Law and Section 306.Eligibility Verification Report 06/04 (Veteran) S-1 Old Law and Section 306 Eligibility Verification Report 06/04 (Surviving Spouse) Old Law and Section 306 Verification Report 06/04 (Children Only) DIC Parent's Eligibility Verification Report 06/ Improved Pension Eligibility Verification 06/04 Report (Veteran With No Children) Improved Pension Eligibility Verification 06/04 Report (Veteran With Children) Improved Pension Eligibility Verification 06/04 Report (Surviving Spouse With No Children) Improved Pension Eligibility Verification 06/04 Report (Surviving Spouse With Children) cl Improved Pension Eligibility Verification 06/04 Report (Child or Children) Application for Exclusion of Children's Income 08/04 TVC Pam hled, Ma 2009,,June Page Commoanly Used Frms (VA, )a[, TVC)

9 Statement in Support of Claim for Service Connection 10/07 For Posttraumatic Stress Disorder a Statement in Support of Claim for Service Connection 10/07 For Posttraumatic Stress Disorder Personal Trauma Examination for Housebound Status or Permanent 06/08 Need for Regular Aid & Attendance Request for Nursing Home Information in 03/04 Connection with Claim for Aid & Attendance Statement in Support of Claim 0/ Authorization and Consent to Release 05/04 Information to VA Statement of Marital Relationship 10/ Supporting Statement Regarding Marriage 11/ Report of Accidental Injury in Support of 10/05 of Claim for Compensation or Pension (Part A)/ Statement of Witness to Accident (Part B) Request for Employment Information in 07/04 Connection with Claim fordisability Benefits Application for Automobile or Other 07/08 Conveyance and Adaptive Equipment b Federal Fiduciary's Account 03/ a Certificate of Balance on Deposit and 10/01 Authorization to Disclose Financial Records Request for Details of Expenses 03/ Medical Expense Report 09/ Disability Compensation Award 02/04 Attachment Important Information Veterans' Application for Increased 10/04 Compensation Based on Unemployability Notice of Waiver of VA Compensation or 03/05 Pension to Receive Military Pay & Allowance DEPARTMENT0'DEFENSEFM Following is a list of DD Forms most commonly used by Service Officers. There are a number of actions pertaining to veterans handled by the Department of Defense (DoD) and require a particular form available on their website at www. dtic.mil/whs/directives/infomgt/forms/formsprogram.htm. The Publication Unit located at VA Regional Offices also maintains most of these same forms. NUMBER TITLE REVISION DATE DD-149 Application for Correction of Military Record 09/07 Under the Provisions of Title 10 DD-293 Application for Review of Discharge 11/06 or Dismissal from Armed Forces MC Pamphlet, AFrmA,Dne 2009 Commonly Used borms (14,JDoJ, T6() Pge6

10 DD Application for Uniformed Services 09/05 Identification (DEERS) DD-2168 Application for Discharge of Member or 04/08 Survivor of Member of Group Certified to have Performed Active Duty with the Armed Forces of the U.S. The following is a list of various TVC forms that are used for Aid & Attendance and other disability claims. These forms are produced and used exclusively in Texas. These forms have been approved by the VA Regional Offices for use in filing claims against VA and are available on the TVC website at tx.us. NUMBER TITLE REVISION DATE TVC-14 Request for Public Records 06/04 TVC-15a Nursing Home Statement 08/00 TVC-15b Assisted Living Statement 08/00 TVC-16 Statement of Attending Physician 06/04 TVC-17 Interview Checklist 10/03 TVC- 18 Claims Tracking Form 11/07 TVC-32 Reporting Unreimbursed Medical Expenses, 06/04 Income & Dependency Changes TVC-M2 Request for Brochures and Publications 02/09 * TVC Pamphlei. May/June 2009 Commonly Used Forms (VA, Do[), TVC)

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