Authorization for Veterans Disability Record

2. Applicant must complete section I, forward to regional office of veteran's administration where disability claim is now on file.

   I hereby authorize you to furnish the Yates County Personnel Office with my medical and disability record. You are released from all liability in complying with this request. It is understood that all information furnished will be treated as confidential.

   I hereby authorize you to furnish the Yates County Personnel Office with my medical and disability record. You are released from all liability in complying with this request. It is understood that all information furnished will be treated as confidential.

4. Veterans Signature

   By typing your name into this field you authorize Yates County to consider this an electronic signature.

6. Address

8. City

9. State

10. Zip Code

12. Service Serial Number

13. Examination or Eligible List for Which Preference is Claimed

    Exam Number and Title

15. Does the Above Veteran Have a War Incurred Disability Now in Existence

    1. Yes
    2. No

16. Is He/She Receiving Disability Payments From the VA for Such Disability

    1. Yes
    2. No

18. State percentage of war-incurred disability now in existence

19. Description of such disability

21. Date of last medical examination by the VA Medical Officer in connection with such disability
    Date of last medical examination by the VA Medical Officer in connection with such disability

    If the date in answer to question 5 is less than one year ago, do not answer the following questions.

23. Does the VA state affirmatively that a permanent stabilized condition of disability exists to an extent of 10% or more, notwithstanding the fact that such claimant has not been examined by a Medical Officer of the VA within one Year?

    1. Yes
    2. No

25. Date of next scheduled medical examination by the VA
    Date of next scheduled medical examination by the VA

26. Remarks

28. Signature of Officer Completing This Form

    By typing your name into this field you authorize Yates County to consider this an electronic signature.

29. Date
    Date

Leave This Blank:


30. 1. Receive email copy
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field