SVC Internal Affairs

Veteran's Informal Statement:



Informal Claim for VA Benefits

Name of Claimant: ____________________________________________________________________
(on the line above, print the same name above if the claimant is the veteran, otherwise,
print the name of the person claiming the benefit on the line above)
With submission of this form, I am filing an Informal Claim for Department of Veterans
Affairs benefits to which I believe the above named veteran would qualify, either for
himself or herself or for a surviving spouse or other dependent.
The veteran above served in the Armed Forces of the United States during the approximate
or actual period of time from ______/_______/_______ to ______/______/______. The veteran
served in the __________________________________ (branch of service) and was discharged
with other than dishonorable discharge.
Service Number ____________________________ Veteran Date of Birth ______/______/______
A Formal Application on behalf of the claimant will be filed for the following VA benefit --- IMPROVED PENSION.


Claimant or veteran signs below. If claimant makes a mark, 2 witnesses must sign also.

Widow's Informal Statement:



Informal Claim for VA Benefits

Surviving Spouse Death Pension and Accrued Benefits

I, ___________________________________________, am filing a claim for Department of Veterans Affairs benefits to which I believe I would qualify. I am the surviving spouse of __________________________________. He served in the Armed Forces of the United States from approximately ___________________ to ________________________. He served in the ____________________________________ and was discharged with an honorable discharged. 



Veteran Birth Date was ___________________________.

Veteran Death Date was ____________________________.

Veteran Service Number ___________________________.

A Formal Application on behalf of the claimant will be filed for the following VA benefit --- IMPROVED PENSION.



Claimant signs below. If claimant makes a mark, 2 witnesses must sign also.