Veterans Services Intake Forms

Section I - Veteran's Identification Information

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Section II - Claimant's Identification Information

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Submit Form

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Veteran's First Name*

Veteran's Middle Initial

Veteran's Last Name*

Veteran's Full Name

Have You Ever Filed a VA Claim?*

Yes

Veteran's Date of Birth*

Branch of Service*

If you are the veteran or claimant, please verify the information below. If you are not the veteran or claimant but are assisting, please enter your information below. Please note we will use below information to create an account.

Full Name: *

Phone Number: *

Email: *

I agree to receive electronic conrrespondence from VA in regards to my claim.

ACCOUNT HOLDER'S MAILING ADDRESS (all fields required)

No. and Street*

Apt/Unit Number

City*

State/Province*

Country*

Zip Code/Postal Code*

I confirm all the information in this form is true. *

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