VA Benefits Claim Checklist Form
Use this form to gather the information needed to review a VA benefits claim for completeness and identify any missing supporting items.
Claimant Information
Full Name
*
First Name
Last Name
Preferred Contact Method
*
Please Select
Phone
Email
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Claim Details
Type of VA Benefit Claimed
*
Disability Compensation
Pension
Education Benefit
Healthcare-Related Benefit
Survivor Benefit
Other
Summary of Claim Issue or Condition
*
Service Period or Branch/Service History
Checklist Readiness
Supporting Documents Available
*
Medical records
Service records
Dependent information
Prior VA decision letters
Other supporting documents
Prior Claim Status
*
New claim
Supplemental claim
Appeal
Not sure
Working With a Representative or Claims Agent
*
Yes
No
Representative Name
First Name
Middle Name
Last Name
Representative Organization
Check Claim Checklist
Should be Empty: