CAUTION: PLEASE BE SURE TO REVIEW VERY IMPORTANT DISCLAIMERS (BELOW), REGARDING GIFTING OR ASSET MOVEMENT WHICH MAY PREVENT THE AWARD OF ANY VA BENEFITS FOR MORE THAN ONE YEAR.
Disclaimer #1: You SHOULD NOT sign or submit this Informal Claim to the VA if ASSETS are in excess of the VA’s current Asset Requirements ($130,773). Further, you should not sign or submit this Form if Assets will be gifted after the signature and/or submission date. - - Such gifting or transfer of assets may adversely affect the award of benefits for a period of at least one year.
Disclaimer #2: The VA Awards a benefit by counting ALL INCOME and QUALIFIED expenses BEGINNING the 1st of the Benefit month established. IF you do NOT have the proper QUALIFIED expenses then this may result in Benefit REDUCTION or DENIAL. Please make sure that you HAVE QUALIFIED expenses to offset the Claimant's income prior to, or shortly after, establishing a Benefit Date. Qualified Expenses DO NOT include your routine daily living expenses.
If you will fully complete the information and “CLAIMANT’S SIGNATURE” in this form (BLOCK 14A) and fax it back to the VA Pension Center this will establish an “informal claim.” This represents only a possible intention to file a formal claim and does not obligate you to file a Fully Developed Claim, or to utilize our services to file a Fully Developed Claim.
IF THIS CLAIM IS FOR A VETERAN (Married or Single)– THE VETERAN IS THE CLAIMANT
IF THIS CLAIM IS FOR A WIDOW – THE WIDOW IS THE CLAIMANT.
HOWEVER, IF THIS IS A WIDOW’S CLAIM, THE DECEASED VETERAN’S INFORMATION MUST ALSO BE PROVIDED.
NOTE 1: The Claimant MUST sign this form (Block 14A). The VA will recognize a Power of Attorney (POA) signature if the claimant is unable to sign. If a POA is signing then an additional form is required. The form is VA Form 21-0972 Alternate Signee Form. The POA will need to complete this form and provide a copy of the Power of Attorney document as well. You will need to submit the Intent to File, Alternate Signee Form and POA document in order to establish a benefit date.
NOTE: This form has a small block in Block 14A which is used if you are able to provide an “Electronic Signature.” The VA does not currently accept an Electronic Signature so DO NOT Sign in this smaller box. Therefore, the Claimant should sign in the larger white space in Block 14A.
Block #3 & Block #10: If you do not know whether or not a previous VA claim has been filed (Block 10), or if you do not have an existing “VA File Number” (Block 3) - these sections can be left blank.
VERY IMPORTANT: Block #13:
If Veterans Claim: Check the "Pension" Block
If a Widows Claim: Check the "Survivors Pension and Indemnity Compensation (DIC)" Block
DO NOT CHECK THE BLOCK MARKED ‘COMPENSATION’ –
AS THIS CAN SIGNIFICANTLY DELAY THE PROCESSING OF THE PENSION CLAIM.
Block #8: If the Service Number is unknown, you can leave this blank.
Block #9: We recommend that you use the mailing address & phone number of a family member. The VA will respond to this address and it is important that correspondence from the VA be handled by a family member so that it can be properly dealt with. –An email address is not required.
Block #15: Leave this area blank
However, to establish the above mentioned benefit date, this form must be faxed to the VA before the end of the last business day of the CURRENT CALENDAR month.
HERE IS THE VA CENTRAL FAX NUMBER: (844) 655-1604
NOTE: This fax number is the VA’s National, “Consolidated” Fax Number that receives thousands of faxes each day.
HEADS UP NOTE: When faxing these forms, we highly recommend that you use a fax machine that produces a “Fax Confirmation” so that you have proof that the fax was sent and received. (For example, Staples, Office Depot, FedX, will provide these). It is not unusual that we have to provide the VA proof that this form was submitted and received by them before the end of the month, and such a “Fax Confirmation” can provide this proof.
AUTOMATIC FAX CONFIRMATION: The VA Fax Center now uses a system that will normally generate an automatic fax back to the number you are faxing from that will also confirm receipt.
NOTE: Several weeks after this Informal Claim is filed with the VA, you should receive a mail package from the VA Pension Center acknowledging receipt of this Informal Claim. Forms may or may not be included with the acknowledgement.