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Forms on this site are available in several formats. Fillable pdf can be filled on-line, printed, saved and edited. XFT forms can be filled on-line, printed, and saved to your pc but cannot be edited later (TURN OFF YOUR POP-UP BLOCKER TO USE XFT). Some PDF are printable blank forms.

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To find a form, enter the form number (example: 12-1234 or 1234) or a word from the form's title or subject.
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Number Title Issue Date Revision Date # Pages
21-0960I-1 Persian Gulf and Afghanistan Infectious Diseases Disability Benefits Questionnaire (Fillable) 06/01/2017 02/2015 2
21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 5
21-0960I-3 Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 3
21-0960I-4 Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 6
21-0960I-5 Nutritional Deficiencies Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 2
21-0960I-6 Tuberculosis Disability Benefits Questionnaire (Fillable) 06/01/2017 02/2015 4
21-0960J-1 Kidney Conditions (Nephrology) Disability Benefits Questionnaire (Fillable) 06/01/2017 02/2015 5
21-0960J-2 Male Reproductive Organ Conditions Disability Benefits Questionnaire (Fillable) 06/01/2017 02/2015 6
21-0960J-3 Prostate Cancer Disability Benefits Questionnaire (Fillable) 06/01/2017 02/2015 3
21-0960J-4 Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 4
21-0960K-1 Breast Conditions and Disorders Disability Benefits Questionnaire (Fillable) 11/22/2016 11/2016 3
21-0960K-2 Gynecological Conditions Disability Benefits Questionnaire (Fillable) 11/22/2016 11/2016 6
21-0960L-1 Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 7
21-0960L-2 Sleep Apnea Disability Benefits Questionnaire (Fillable) 11/22/2016 11/2016 2
21-0960M-1 Amputations Disability Benefits Questionnaire (Fillable) 05/24/2017 12/2014 4
21-0960M-10 Muscle Injuries Disability Benefits Questionnaire (Fillable) 05/24/2017 12/2014 6
21-0960M-11 Osteomyelitis Disability Benefits Questionnaire (Fillable) 11/22/2016 11/2016 4
21-0960M-12 Shoulder and Arm Conditions Disability Benefits Questionnaire (Fillable) 05/07/2014 05/2013 9
21-0960M-13 Neck (Cervical Spine) Disability Benefits Questionnaire (Fillable) 05/07/2014 05/2013 11
21-0960M-14 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire (Fillable) 05/07/2014 05/2013 11
21-0960M-15 Temporomandibular Joint (TMJ) Conditions Disability Benefits Questionnaire (Fillable) 05/24/2017 12/2014 3
21-0960M-16 Wrist Conditions Disability Benefits Questionnaire (Fillable) 05/07/2014 05/2013 8
21-0960M-2 Ankle Conditions Disability Benefits Questionnaire (Fillable) 08/08/2017 08/2017 9
21-0960M-3 Non-Degenerative Arthritis (Including Inflammatory, Autoimmune, Crystalline and Infectious Arthritis) and Dysbaric Osteonecrosis Disability Benefits Questionnaire (Fillable) 05/07/2014 05/2013 6
21-0960M-4 Elbow and Forearm Conditions Disability Benefits Questionnaire (Fillable) 06/21/2017 06/2017 9
21-0960M-6 Foot Miscellaneous (Other Than Flatfoot/PES Planus) Disability Benefits Questionnaire (Fillable) 05/07/2014 05/2013 9
21-0960M-7 Hand and Finger Conditions Disability Benefits Questionnaire (Fillable) 05/07/2014 05/2013 15
21-0960M-8 Hip and Thigh Conditions Disability Benefits Questionnaire (Fillable) 06/16/2017 06/2017 10
21-0960M-9 Knee and Lower Leg Conditions Disability Benefits Questionnaire (Fillable) 06/28/2017 06/2017 10
21-0960N-1 Ear Conditions (Including Vestibular and Infectious Conditions) Disability Benefits Questionnaire (Fillable) 11/22/2016 11/2016 5
21-0960N-2 Eye Conditions Disability Benefits Questionnaire (Fillable) 05/24/2017 12/2014 10
21-0960N-3 Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire (Fillable) 12/14/2016 09/2016 2
21-0960N-4 Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 6
21-0960P-1 Eating Disorders Disability Benefits Questionnaire (Fillable) 06/01/2017 02/2015 2
21-0960P-2 Mental Disorders (Other Than PTSD and Eating Disorders) Disability Benefits Questionnaire (Fillable) 06/08/2017 02/2015 5
21-0960P-3 Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire (Fillable) 06/01/2017 02/2015 6
21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnaire (Fillable) 11/21/2016 09/2016 3
21-0966 Intent To File A Claim For Compensation and/or Pension, or Survivors Pension and/or DIC 06/15/2017 03/2017 1
21-0972 Alternate Signer Certification 12/20/2016 10/2016 3
21-22 Appointment of Veterans Service Organization as Claimant's Representative (Fillable) 08/03/2017 08/2015 2
21-22a Appointment of Individual As Claimant's Representative (Fillable) 12/10/2015 08/2015 2
21-2680 Examination for Housebound Status or Permanent Need For Regular Aid and Attend. (Fill) 09/03/2015 05/2015 2
21-4138 Statement in Support of Claim (Fillable) 01/12/2017 01/2015 2
21-4140-1 Employment Questionnaire (Fillable) 08/14/2012 08/2011 1
21-4142 Authorization to Disclose Information to the Department of Veterans Affairs(VA) (Fillable) 07/08/2015 6/2014 3
21-4142a General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (Fillable) 09/04/2014 6/2014 1
21-4170 Statement of Marital Relationship (Fillable) 07/21/2016 09/2014 2
21-4192 Request for Employment Information in Connection With Claim for Disability Benefits (Fillable) 09/14/2017 09/2017 2
21-4502 Application for Automobile or Other Conveyance and Adaptive Equipment (Fillable) 03/23/2015 02/2015 4
21-526 Veterans Application for Compensation and/or Pension (Fillable) 11/19/2014 11/2014 10
 
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