va form 21 0960l 2

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OMB Control No. 29000778 Respondent Burden: 15 Minutes Expiration Date: 09/30/2019SLEEP APNEA DISABILITY BENEFITS QUESTIONNAIRE IMPORTANT THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE
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S. Department of Veterans Affairs for a disability rating within 30 days following the date of discharge from an institution covered by the VIA. The applicant must provide the information necessary to determine whether the applicant is entitled to a VA disability rating within 30 days after discharge from the institution. VA will attempt to contact the applicant when required for this application. VA is requesting that the Social Security Numbers provided by the applicant, as verified or confirmed by a social security card, U.S. Driver's License, or other acceptable government document, or by other approved method, be included on the disability evaluation in order to avoid delays while waiting for a social security number to be verified (if available) and a VA card to be provided (if not available). If it is determined that the social security numbers are not needed to verify the applicant's eligibility to receive a VA disability rating, the applicant will be notified that VA will not pay, or reimburse any administrative expense associated with verification and/or request an alternate method of verification, such as a telephone. Social Security Numbers are needed for VA to determine applicant eligibility for benefits. If social security numbers are not provided, the applicant will be required to submit additional documentation. If required, the social security numbers will also be used for the purpose of verification of an applicant's eligibility for benefits. The Social Security Number (SSN) must be provided in one of three ways (each listed below) to ensure accuracy and completeness of the disability application. The SSN must be verified from either the applicant's prior government record or other acceptable government document. The Social Security Number must be provided by the applicant's prior employer, if applicable. It can be obtained as part of the job application; the employer's records are available for verification; or through administrative information (e.g. tax returns, pay stubs) or information available on the applicant's record or the applicant's application. If Social Security Numbers are not provided, VA will require the applicant to provide another method of verification and/or request an alternate method of verification, such as a telephone. The method of verification required depends on the type of disability for which an application is submitted: 1) Supplemental Security Income (SSI) 2) VA Disability Rating System 3) Eligibility for VA Medical Care 4) Medical Disparities Program 5) Eligibility for VA Insurance 6) Application for VA Federal Student Loan 7) Military Records 8) Any other form of Social Security Number verification provided by the applicant.
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