VA Form 21-526EZ Example: Filling Out the 2026 Form

This is a fictional, completed example of the current VA Form 21-526EZ, the January 2026 edition, taken in form order from Item 1 to the signature. Most of the form is identification and service history. The part that decides what VA will consider is Section V, Item 16, where you list each condition, the event or exposure behind it, how it relates to service, and when it began. The example shows three Item 16 rows: a direct injury, a secondary condition and an exposure-related condition.

The veteran below, Alex Morgan, is invented. Never copy invented facts onto your application. The form itself says that if this is not your original claim, only Section I, Section IV if it applies, Section V and a signature are required. You can also file the same application online at VA's how to file page; the online version asks the same questions.

Use this form for disability compensation, including a new condition or a rating increase. If you disagree with a decision VA already made, use a decision review form instead; the form itself points you to VA Form 20-0995 for Supplemental Claims.

Item 1: Choose the claim process

Section I: Veteran's identification (Items 2 to 12)

Sections II and III: Address change and homeless information

Section II (Items 13A to 13C) is only for a temporary or permanent address change, with the dates it takes effect. Section III (Items 14A to 14F) is only for veterans who are homeless or at risk of homelessness, with a point of contact VA can reach. Alex skips both.

Section IV: Exposure information (Items 15A to 15E)

Item 15A asks whether you are claiming any condition related to toxic exposure. If yes, complete 15B to 15E:

Answer Section IV only for conditions you believe relate to an exposure. It does not replace listing the condition in Item 16.

Section V: Item 16, the claimed conditions

Item 16 has four columns: the current disability or symptom; the exposure, event or injury, if any; how the disability relates to that in-service event, exposure or injury; and the approximate date it began or got worse. The form prints three examples of its own: hearing loss from noise as a heavy equipment operator (July 1968), diabetes from Agent Orange during Vietnam service (December 1972), and "left knee, secondary to right knee," injured when a brace on the right knee failed (6/11/2008). The third shows how to write a secondary condition: name it, then add "secondary to" and the condition that caused it.

Alex's three fictional rows:

Each row names one condition. A record uploaded under the knee does not claim the hip; the hip needs its own row. Write "approximate" when you are not sure of a date, and describe a symptom as a symptom if you have no diagnosis yet. If you run out of the 15 rows, use Section XIII.

Item 16's columns line up with three common reasons the Board gives for denials. In Claim Raven's analysis of 2024 to 2025 Board decisions, among denied condition records with a classified main reason, no link between the condition and service (no nexus) was 22.9%, service connection not shown was 17.0%, and no current diagnosis was 16.3%. These are appeals of claims already in dispute, so the shares describe patterns, not your odds; Claim Raven's analysis of classified Board denials explains the method.

Section V: Item 17, VA and military treatment after discharge

Item 17 asks for VA medical centers and DoD military treatment facilities where you were treated for the Item 16 conditions after discharge. Column A is the disability treated and the facility name and location; column B is the approximate start date (month and year); column C is a box to check if you do not have dates. The form says you do not need dates if treatment began in 2005 or later.

Private doctors do not go here. Alex lists the private orthopedic clinic on Forms 21-4142 and 21-4142a so VA can request those records.

Below Item 17, the form lists extra forms for certain claims, including VA Form 21-0781 for a mental health condition, Forms 21-8940 and 21-4192 for individual unemployability, and Form 21-686c for dependents.

Section VI: Service information (Items 18A to 23B)

Section VII: Service pay (Items 24A to 28)

This section asks about military retired pay (24A to 25), separation pay, disability severance pay or other lump sums (27A to 27D), and training pay. Alex receives none and answers No. Items 26 and 28 are boxes that say "Do NOT pay me VA compensation." Leave them blank unless you have decided to keep retired pay or training pay instead of VA compensation, because the form warns that checking them means you will not receive VA compensation.

Section VIII: Direct deposit (Items 29 to 32)

If you already have direct deposit set up with VA, skip this section. Otherwise enter the account number and type, the bank name and the routing number, or check Item 29 if you have no bank account. Alex enters account details.

Section IX: Certification and signature (Items 33A and 33B)

By signing, you certify that the statements are true, authorize others to give VA information about you, confirm you received VA's notice about the evidence needed, and confirm either that you enclosed your evidence or that you chose the standard claim process because you plan to send more. Alex signs and dates the form.

Sections X to XII apply only when someone other than you signs: two witnesses if you sign with an "X," an alternate signer with VA Form 21-0972, or a representative with power of attorney on file. The form notes that a representative cannot sign an original claim under Section XII. Section XIII is the addendum page for more Item 16 rows.

Submit it and keep proof

VA's instructions on the form say you can apply online and upload your supporting documents with the claim, or mail the paper form to Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444. VA's filing page also lists in-person filing at a regional office and help from an accredited representative. Starting the online application sets your intent to file automatically; on paper, VA suggests submitting an intent to file first. Keep a complete copy of what you sent and the confirmation or delivery proof. After filing, you have up to one year to send more evidence, but the form says VA may decide sooner if it asks for information and you do not respond within 30 days.

For the full filing sequence, including whether to work with a representative, see the guide to filing a VA disability claim. Claim Raven's help center also has a final package check for Form 21-526EZ.

Claim Raven sells claim-preparation tools, including the one linked on this page, and has a commercial interest in them.

Sources and scope

Checked September 23, 2026: VA Form 21-526EZ (VA's form page lists the January 2026 revision; the PDF supersedes the November 2022 edition) and its printed instructions, VA's how to file page, and the Fully Developed Claims page. Board figures come from Claim Raven's analysis of 2024 to 2025 decisions and count condition records. Alex Morgan and every entry above are fictional.