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VA Form Examples
Completely filled-out sample forms showing exactly what strong, correct submissions look like. Use these as your guide when completing your own forms. All names and details are fictional examples.
Example: VA Form 21-526EZ
Application for Disability Compensation and Related Compensation Benefits
Section I — Veteran Identification
Johnson
Marcus
T
XXX-XX-1234 (Example)
03/15/1985
Not yet assigned — first claim
1234 Veteran Way, San Antonio, TX 78201
(210) 555-0147
marcus.johnson@email.com
Male
Section II — Military Service
United States Army
06/10/2005
06/09/2013
Active Duty
Honorable
11B — Infantryman
Tip: List ALL periods of service including reserves and guard. Each period gets its own entry. Your DD-214 has the exact dates.
Section III — Disabilities Being Claimed
Critical: List every condition you want to claim. You can always withdraw a claim but you cannot add one with an earlier effective date later. When in doubt — list it.
Post-Traumatic Stress Disorder (PTSD)
List the condition as diagnosed or as you know it
Developed during combat deployment to Iraq (OIF) 2007–2008, exposure to direct combat including IED blasts and combat operations in Ramadi
Lumbar Spine Strain / Lower Back Pain
Sustained during patrol operations carrying 60+ lb ruck over uneven terrain. Treated at FOB medical facility September 2007 and Fort Hood medical center 2012.
Tinnitus (ringing in ears)
Chronic tinnitus resulting from prolonged exposure to weapons fire, explosions, and military equipment noise throughout 8 years of service.
Sleep Apnea — Secondary to PTSD
Secondary condition: sleep apnea developed as result of PTSD medication (Prazosin) causing weight gain and sleep disruption directly related to service-connected PTSD.
Section IV — Direct Deposit Information
Checking
XXXXXXXXX (your bank's routing number)
XXXXXXXXXX (your account number)
Section V — Signature
Marcus T. Johnson
05/15/2025
Before submitting: Upload all supporting evidence — service records, medical records, buddy statements, nexus letters. A fully developed claim processes faster and gets better results.
Example: VA Form 21-0781
Statement in Support of Claim for PTSD
Veteran Identification
Johnson, Marcus T.
XXX-XX-1234
03/15/1985
In-Service Stressor Event #1
This section is critical. Be as specific as possible. The VA uses this to verify the stressor. Include dates, locations, unit, names of others present if possible, and what happened. Do not minimize or be vague.
August 14, 2007
Ramadi, Al Anbar Province, Iraq — Route Michigan, approximately 2 miles west of Government Center
1st Battalion, 6th Infantry Regiment, 1st Armored Division, Fort Bliss, TX. Deployed OIF 2007–2008.
While conducting a mounted patrol on Route Michigan, our convoy struck a buried IED (improvised explosive device). The vehicle immediately ahead of mine (Vehicle 2 in the convoy) was destroyed by the blast. Private First Class Daniel Reeves, age 19, was killed instantly. Specialist Kevin Torres lost his right arm below the elbow. I was in Vehicle 3 and was thrown against the interior of the vehicle. I got out and ran to Vehicle 2 under continued small arms fire to render aid. I held PFC Reeves as he died. I cannot get the image out of my mind. I was responsible for my team's safety and I have never stopped questioning whether I could have done something differently.
Following the blast, our unit came under sustained small arms fire from multiple directions for approximately 35 minutes before air support arrived. Three additional soldiers were wounded during that engagement.
Staff Sergeant Robert Caldwell — served in same unit, present during the incident. Contact information on file with unit records. Specialist (Ret.) Kevin Torres — survived the blast, lost limb. Currently resides in El Paso, TX.
In-Service Stressor Event #2 (if applicable)
November 3, 2007
During a dismounted patrol in central Ramadi, our unit discovered 3 civilian bodies, including a child approximately 8 years old, who had been executed near a market. I was the first soldier to reach the scene and had to secure and photograph the area. I have recurring nightmares specifically about this event.
Current PTSD Symptoms
I have nightmares 4–5 nights per week reliving the IED blast and the deaths I witnessed. I wake up in a cold sweat and am unable to sleep for 2–3 hours afterward. I have 3–4 panic attacks per week triggered by loud noises, crowded spaces, and driving near construction sites or overpasses. I avoid highways entirely. I have been unable to maintain steady employment — I was terminated from two jobs for angry outbursts in the workplace. My marriage ended in 2021 in large part due to my emotional withdrawal and unpredictable anger. I have been in VA mental health treatment since 2014 with Dr. Sarah Williams at the San Antonio VAMC.
Key tip: Describe the event in as much detail as you can remember. It doesn't have to be perfect — the VA understands that traumatic memories can be fragmented. What matters is that you describe a real event that caused real trauma. The more specific the better — dates, locations, unit designations, names of others present.
Example: VA Form 21-8940
Veteran's Application for Increased Compensation Based on Unemployability (TDIU)
Part A — Veteran Identification
Johnson, Marcus T.
28-XXXXXXX
XXX-XX-1234
Part B — Employment History
This section is critical for TDIU. Document every job, every termination, every period of unemployment. Show the pattern — that your service-connected disabilities are what prevents you from working, not unrelated factors.
Amazon Distribution Center, San Antonio TX
03/2014 – 08/2015
Terminated. Documented reasons: missed 22 days in 6 months due to PTSD episodes and back pain flare-ups. Final incident: panic attack on warehouse floor requiring emergency response. HR documentation available.
U.S. Postal Service, San Antonio TX (Rural Carrier)
01/2017 – 06/2018
Terminated following 3-step progressive discipline process. Unable to drive route without severe anxiety episodes when passing construction zones and bridges. Back pain made prolonged sitting and lifting mail trays impossible after 2 hours. Supervisor documentation available.
Part C — How Disabilities Prevent Substantially Gainful Employment
My service-connected PTSD (currently rated 70%) and lumbar spine strain (rated 40%) together create a combination of symptoms that make maintaining any form of substantially gainful employment impossible.
PTSD symptoms affecting employment: I have severe panic attacks 3–4 times per week, triggered by noise, crowds, and high-stress environments — all common in any workplace. I have been involved in 3 documented workplace incidents involving verbal confrontations I could not control. I cannot maintain a regular schedule because severe nights (nightmares, 2–4 AM wake-ups) make mornings nonfunctional 3–4 days per week. I have difficulty concentrating and following multi-step instructions on bad days.
Back pain symptoms affecting employment: My lumbar spine condition limits me to sitting no longer than 20–25 minutes without severe pain (8–9/10). Standing more than 30 minutes causes radiating pain down my left leg. I cannot lift more than 15 lbs consistently. This eliminates most physical work. On flare-up days (5–8 per month) I cannot get out of bed.
Combined effect: I have been unable to maintain employment for more than 18 months in any position since my 2013 separation. I am currently not employed and have not been employed since June 2018. My VA mental health provider, Dr. Sarah Williams, and my primary care physician, Dr. James Carter, both support that my service-connected conditions prevent me from maintaining substantially gainful employment.
Part D — Education
Some college — 42 credit hours, University of Texas San Antonio (attempted while working, could not complete due to disability)
None completed — attempted VR&E in 2016, withdrawn due to inability to attend consistently due to PTSD symptoms
TDIU threshold reminder: You need ONE condition rated 60%+ OR a combined rating of 70%+ with at least one condition at 40%+, AND evidence that you cannot maintain substantially gainful employment. The employment history and the description of how your disabilities prevent work are the two most important sections.
Example: VA Form 21-10210
Lay Witness Statement (Buddy Statement)
Part A — Claimant/Veteran Information
Johnson, Marcus T.
28-XXXXXXX
03/15/1985
Part B — Witness Information
Johnson, Alicia M.
Former spouse (married 2009–2021)
14 years
5678 Oak Street, San Antonio, TX 78210
(210) 555-0189
Part C — Statement
This is the most important part. Specific examples always win over general statements. "He seemed sad" is weak. "On March 14, 2019, he locked himself in the bedroom for 3 days and would not eat or speak" is strong.
I am providing this statement in support of my former husband Marcus Johnson's VA disability claim. I knew Marcus before he deployed to Iraq in 2007 and I witnessed firsthand the dramatic change in him after he returned in 2008.
Before deployment, Marcus was outgoing, social, and worked without problems. He was a good husband, attentive and present. When he came home, he was a different person.
What I personally witnessed after his return:
SLEEP: For the entire 13 years of our marriage after his return, Marcus had nightmares multiple times per week. I was woken up by him screaming, thrashing, and once choking me in his sleep during a nightmare. I counted in a journal I kept: in March 2015, he had nightmares 19 out of 31 nights.
PANIC ATTACKS: I witnessed at least 50 panic attacks during our marriage. The worst ones happened in crowded places. At our daughter's school play in 2016, he had to leave the auditorium and I found him in the parking lot hyperventilating, unable to speak for 20 minutes.
ANGER AND ISOLATION: Marcus would go days without speaking to me or the children. He stopped attending family events, church, and eventually stopped leaving the house except for essential tasks. When he did interact, he would have explosive anger episodes over minor things — a dropped glass in 2018 resulted in him punching a hole in the wall and leaving the house for 3 days.
WORK: I watched Marcus lose two jobs during our marriage. At Amazon, I picked him up after a panic attack on the floor. He cried the entire drive home and said he felt like a failure. He tried so hard.
The reason I am providing this statement is that I know beyond any doubt that these behaviors are connected to what he experienced in Iraq. The man I married before that deployment does not exist anymore. He was replaced by someone suffering deeply, every single day.
I certify that these statements are true and accurate to the best of my knowledge.
Signature
Alicia M. Johnson
05/15/2025
Example: VA Form 20-0995
Decision Review Request — Supplemental Claim
Part A — Veteran Identification
Johnson, Marcus T.
28-XXXXXXX
03/15/1985
Part B — Issues Being Appealed
List each condition being appealed separately. For each one, explain what the VA decided and what you believe is wrong with the decision. Be specific.
Post-Traumatic Stress Disorder (PTSD)
March 10, 2025
The VA rated my PTSD at 50%. I believe this is too low based on the severity of my symptoms. The C&P examiner noted my symptoms as "moderate" — however, I experience panic attacks more than once per week, near-daily sleep impairment, and I have been terminated from two jobs due to PTSD symptoms. These symptoms meet the criteria for a 70% rating under 38 CFR § 4.130.
Part C — New and Relevant Evidence
For a Supplemental Claim, you must submit new and relevant evidence. This is what makes this different from a Higher-Level Review. List every piece of new evidence you are attaching.
1. Updated treatment records from San Antonio VAMC Mental Health Clinic, January–April 2025 (documenting increased panic attack frequency and emergency room visit 02/14/2025 for acute PTSD episode)
2. Letter from treating psychologist Dr. Sarah Williams, LCSW, dated 05/01/2025, documenting symptoms consistent with 70% rating criteria
3. Buddy statement from former spouse Alicia Johnson describing witnessed symptoms including documented 19 nightmares in March 2015 and two witnessed panic attacks
4. Employment termination records from Amazon (09/2015) and USPS (06/2018) showing termination directly related to PTSD symptoms
5. Personal statement from veteran dated 05/10/2025 describing worst-day functioning
Signature
Marcus T. Johnson
05/15/2025
File within 1 year of your decision letter to preserve your existing rating and effective date. Attach ALL new evidence when you file — don't submit the form and send evidence separately if you can avoid it.
Example: VA Form 20-0996
Decision Review Request — Higher-Level Review
Important: The Higher-Level Review does NOT allow new evidence. Use this when you believe the VA made a legal or factual error in the original decision — not when you have new information to add. For new evidence, use Form 20-0995 (Supplemental Claim).
Veteran Identification
Johnson, Marcus T.
28-XXXXXXX
03/15/1985
Issues on Appeal
Sleep Apnea — Secondary to PTSD
March 10, 2025
The VA denied service connection for sleep apnea stating "no nexus to service has been established." This is a clear error of fact. My claim file contains a nexus letter from Dr. James Carter, MD, dated January 15, 2025, which states that my sleep apnea is "at least as likely as not" caused by weight gain from Prazosin, which was prescribed for my service-connected PTSD. This nexus letter appears to have been ignored or overlooked by the original rater. The VA's duty to assist requires consideration of all submitted evidence. I am requesting that a senior reviewer re-examine my claim file and reconsider this nexus letter.
Informal Conference Request
✓
Yes — I request an informal conference with the reviewer to discuss the error in my claimMonday–Friday, 2:00 PM – 5:00 PM Central Time at (210) 555-0147
Request the informal conference. It gives you a chance to speak directly with the reviewer and explain the error. Most veterans don't request it — those who do often have better outcomes.
Example: VA Form 21-686c
Declaration of Status of Dependents — Adding Spouse & Children
Money tip: Adding a spouse to a 30% rating adds approximately $158/month. Adding a child adds approximately $85/month. If you have dependents and haven't filed this form — do it today. The effective date goes back to when you first had the dependent, or your rating date, whichever is later.
Veteran Identification
Johnson, Marcus T.
28-XXXXXXX
Adding a Spouse
Williams, Jasmine R.
06/12/2022
San Antonio, Bexar County, Texas
09/24/1987
XXX-XX-5678
Adding a Child
Johnson, Aiden Marcus
03/28/2010
XXX-XX-9012
Biological child — natural born
No
Documents to attach: Marriage certificate for spouse. Birth certificate for each child. Adoption decree if adopted. School enrollment verification if child is 18–23 and in school full-time.
Example: VA Form 21-0966
Intent to File — Protecting Your Effective Date
This is the most important 5-minute action you can take. Filing an Intent to File locks in today's date as your potential effective date. Every month you delay costs you back pay. A veteran who files an ITF today and submits their full claim 6 months later gets 6 months of back pay. A veteran who waits and files everything together gets nothing for those 6 months.
Veteran Information
Johnson, Marcus T.
XXX-XX-1234
03/15/1985
1234 Veteran Way, San Antonio, TX 78201
(210) 555-0147
Type of Benefit
✓
Compensation (Disability)Pension
Survivors Pension or DIC
Signature
Marcus T. Johnson
05/15/2025
⚠️ This date becomes your effective date. Keep a copy.
After filing your ITF: You have 1 year to submit your fully developed claim. Don't wait — start gathering evidence immediately. Your ITF confirmation number is your proof of the effective date.
Example: VA Form 10-10EZ
Application for Health Benefits — VA Healthcare Enrollment
Why this matters for your claim: Enrolling in VA healthcare creates a VA treatment record. Every appointment where you describe your symptoms becomes evidence in your claims file. Enroll as soon as possible — even if you have other insurance.
Personal Information
Johnson
Marcus
Thomas
03/15/1985
XXX-XX-1234
Male
1234 Veteran Way, San Antonio, TX 78201
(210) 555-0147
Military Service
Army
06/10/2005
06/09/2013
Honorable
Yes — Iraq (OIF) 2007–2008
Financial Information
If you have a service-connected disability rating, your priority group is automatically higher — you may not need to provide financial information. Check the box for service-connected disability.
✓
I have a VA service-connected disability rating70% service-connected (PTSD, back pain, tinnitus, sleep apnea)
After enrolling: Schedule your first primary care appointment and ask specifically to be referred to mental health services. At your first appointment, describe ALL your conditions — physical and mental. What gets documented at that first appointment begins building your claims evidence file.
Example: VA Form 22-1990
Application for VA Education Benefits (Post-9/11 GI Bill)
Before applying: If you have a service-connected disability rating of 20%+, compare VR&E (Chapter 31) with the GI Bill. VR&E often pays significantly more — full tuition with no cap plus a housing stipend. See the VR&E guide in your members area.
Veteran Information
Johnson, Marcus T.
XXX-XX-1234
03/15/1985
Education Benefit Selection
✓
Chapter 33 — Post-9/11 GI Bill (best for most veterans with post-9/11 service)Chapter 30 — Montgomery GI Bill Active Duty
Chapter 1606 — Montgomery GI Bill Selected Reserve
School / Program Information
University of Texas at San Antonio
San Antonio, TX
Bachelor of Business Administration — Management
Full-time undergraduate — in-person
08/25/2025
College degree program — 4-year institution
After approval: Bring your Certificate of Eligibility (COE) to your school's Veterans Certifying Official. They process your enrollment certification with VA. Do this before or at registration — not after — to ensure timely housing allowance payments.
Example: VA Form 28-1900
Disabled Veterans Application for Vocational Rehabilitation (VR&E / Chapter 31)
VR&E key advantage: Unlike the GI Bill, VR&E has NO tuition cap and pays a monthly housing stipend on top of tuition. For a veteran attending a 4-year university, VR&E can be worth $10,000–$30,000 more than the GI Bill over the program duration.
Veteran Information
Johnson, Marcus T.
28-XXXXXXX
03/15/1985
70% service-connected
06/09/2013
Employment Handicap — This Is the Key Section
How you describe your employment handicap determines your eligibility. Be specific about how your service-connected disabilities create a barrier to finding and keeping suitable employment. This is your opportunity to establish eligibility — don't be vague.
My service-connected disabilities — PTSD (70%), lumbar spine (40%), tinnitus (10%), and sleep apnea (50%) — create significant barriers to maintaining substantially gainful employment.
My PTSD causes panic attacks in workplace environments, difficulty maintaining consistent attendance due to severe sleep disruption, and explosive episodes that have resulted in termination from two positions. Crowded workplaces, supervisory pressure, and noise triggers all exacerbate my PTSD symptoms significantly.
My lumbar spine condition limits prolonged sitting (max 20–25 minutes), standing (max 30 minutes), and lifting (max 15 lbs). This eliminates most physical occupations and requires frequent position changes that are incompatible with most traditional work environments.
My sleep apnea and tinnitus further impair my cognitive functioning, concentration, and ability to process information quickly — skills required for most knowledge-work positions.
I am interested in pursuing VR&E to obtain training in a career that can accommodate my limitations — specifically, I am interested in remote IT work or business operations that allow flexible scheduling and remote work to manage my PTSD triggers.
Career Goal
Information Technology — specifically cybersecurity or network administration. Remote-compatible, limited public interaction, technical work that matches my analytical skills developed during military service. I am willing to complete necessary certifications or a degree program to achieve this goal.
At your intake appointment: Your VR&E counselor will determine which of the 5 tracks best fits your situation. Push for the "Employment Through Long-Term Services" track if you want a degree. Don't let the counselor steer you toward a quicker lower-paying track unless that is genuinely what you want. You have the right to advocate for your own rehabilitation plan.
Example: Standard Form 180 (SF-180)
Request Pertaining to Military Records — National Personnel Records Center
Get your records before you need them. Service treatment records (STRs) are the foundation of every VA claim. Don't wait until you've filed to request them — the process can take 30–90 days. Request everything now.
Section I — Information Needed to Locate Records
Johnson
Marcus
Thomas
XXX-XX-1234
03/15/1985
Houston, Texas
Army
06/10/2005
06/09/2013
SSN used as service number post-1974
3rd Battalion, 1st Infantry Regiment, Fort Bliss, TX
Section II — Records Requested
✓
DD-214 (Certificate of Release or Discharge from Active Duty) — ALL copies✓
Service Treatment Records (Medical Records) — COMPLETE file✓
Official Military Personnel File (OMPF)✓
Deployment orders and all records related to Iraq deployment 2007–2008Purpose of Request
VA disability compensation claim. I need my complete service treatment records, DD-214, and deployment records to support my disability claim for PTSD, back pain, tinnitus, and sleep apnea. Please provide ALL records including sick call visits, mental health records, injury reports, and deployment documentation.
Request EVERYTHING. Be broad in your request. You can always not use a record, but you can't unclaim something you forgot to request. Specifically ask for mental health records — these are sometimes filed separately and easy to miss.