LAW OFFICE OF

MATTHEW BONEY

file a vA disability claim

Name

Name used in service if different:

Applicant if other than veteran:

Relationship to veteran:

Physical Address:

Mailing Address:

Telephone:

E-mail

Date of Birth

Social Security Number:

Martial Status

Education:

If you are not yourself the veteran, and your application is based on the eligibility of a veteran who is a member of your family-your spouse or your parent, for example-please answer the questions below if you were the veteran.

Were you ever station or have you ever served at Camp Lejeune?

Yes

If so, during what year(s)

Were you in combat?

Yes

Were you wounded?

Yes

If so, where on the body?

Are you still having medical problems caused by the wound(s)?

Yes

If so, what are the problems?

Were you ever a prisoner of war?

Yes

If yes, where and for how long?

Do you have recurring dreams or intrusive memories about combat or your POW experience?

Yes

I was never a POW

Are you currently being treated or have you ever been treated at a hospital for an illness or disability incurred in or aggravated by service?

Yes

Do you have recurring dreams or intrusive memories about any traumatic experience during military service (one that involved feelings of intense fear, helplessness, or horror)?

Yes

Do you avoid, or react unusually to, things that symbolize or remind you of a traumatic event in service?

Yes

Were you treated for any injury, disability, or disease in service?

Yes

If yes, briefly describe the disability or disease:

Are you currently having problems with these same disabilities or diseases?

Yes

If yes, briefly describe the problems. Be sure to describe how your disability interferes with your work:

Are you currently suffering from a disability or disease whose symptoms appeared within one year after discharge from service?

Yes

If yes, describe:

Did you suffer from a disease or injury in service that was not treated by a doctor?

Yes

If so, describe:

Do you currently have a disease or injury that existed before your entry into service?

Yes

If yes, describe:

Did the disease or injury increase in severity (get worse) during service?

Yes

While in service, were you exposed to:

Radiation

Yes

Agent Orange

Yes

Asbestos

Yes

Toxic Chemicas

Yes

Nerve Gas

Yes

Depleted Uranium

Yes

Smoke from Buring Oil Wells

Yes

Other

Yes

If you answered yes for "other" please describe:

Information related to VA Benefits

Have you ever applied for VA Benefits?

Yes

If yes, check all that apply:

Compensation

Medical Care

Vocational Rehabilitation

Domiciliary Care

Pension

Education

Nursing Home

Home loan guaranty

Other (please specify)

If you have filed a claim before, please give the claim number that the VA assigned:

Are you now receiving VA benefits?

Yes

If yes, check all that apply:

Compensation

Pension plus aid and attendance benefit

Pension plus housebound benefit

Medical care

Vocational rehabilitation

Domiciliary care

Pension

Education

Nursing home

Home loan guaranty

Other (please specify)

At which VA regional office is your claim file located?

Were you ever treated at a VA medical center?

Yes

If yes, please specify when, where and what the treatment was for:

Have you ever sought counseling or help from a Vet Center?

Yes

If yes, please specify when and where:

Are you currently employed?

Yes

If not employed, are you able to work?

Yes

If you are not employed, is it because of medical problems related to your military service?

Yes

Are you receiving Social Security Disability, Supplemental Social Security, or other forms of government assistance? If you are, please specify

Do you have dependents?

Yes

If you have dependents, how many?

If you are a veteran, please attached a copy of your discharge form, DD 214. If you do not have a copy of your DD 214, please indicate this in the next question in order to obtain a Standard Form (SF) 180, Request Pertaining to Military Records, to obtain a copy of your DD 214.

DD 214 Upload

Please choose an option below

I do not have copy of my form DD 214. Please email me a copy of Form SF 180 so that I may submit a request for my Form DD 214

I will email a copy of my form DD 214 to info@matthewboney.com after submission of this application

To what branch of service (army, navy, air force, marines, coast guard, merchant marine) did you belong?

To what era (Korea, Vietnam, Persian Gulf, OEF/OIF, or other) was your service

Please list all your dates of service: (Example: Entry____ Discharge___)

Please state your type of discharge:

Were you discharged because of:

Completion of your obligation

Downsizing

Physical disability

Other reason

If you chose "Other Reason" for the previous question, please specify

Are you receiving retirement pay from the military?

Yes

If you chose yes for the previous question, what is the monthly amount?

Are your receiving disability pay from the military?

Yes

If yes, please specify the amount:

Did you receive severance pay at discharge:

Yes

If yes, specify the amount received:

Are you now being treated, or have you been treated in the past, by a private physician for an illness or disability incurred in or aggravated by service?

Yes

If yes, provide the dates (s) on which you were treated and the name and address of the physician:

Are you currently being treated or have you ever been treated at a hospital for an illness or disability incurred in or aggravated by service?

Yes

If yes, provide the date(s) you were treated and the name and address of the physician:

List any other information or comments that may be helpful:

List all current disabilities:

Special note to Attorney:

Disclaimer: Nothing provided in this website should be considered legal advice or legal opinion. This web site is not intended to create an attorney-client relationship or otherwise open a file. Please contact one of our attorneys to schedule an office conference for personal and confidential advice concerning your legal matter. The choice of a lawyer is an important decision and should not be based solely upon advertisements. Licensed in the following jurisdictions: US Tax Court, Immigration Court and the U.S. 4th Circuit Court of Appeals which encompasses NC, MD, SC, VA and WV. Matthew Boney does not practice issues of NC law nor is he licensed by the NC Bar. Should you have questions in regards to North Carolina law you should consult an NC licensed attorney. You may call the NC Bar referral service at (919) 677- 8574.

Any reliance on the information contained in this correspondence by someone who has not entered into a fee agreement with THE LAW FIRM OF MATTHEW BONEY is taken at the reader’s own risk.

MATTHEW L. BONEY & ASSOCIATES

POST OFFICE BOX 70184

MYRTLE BEACH, SOUTH CAROLINA 29572