VA Form 21-2680: Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

What VA Form 21-2680 is for

VA uses Form 21-2680 to decide eligibility for aid and attendance or housebound benefits, paid as Special Monthly Compensation (SMC) or Special Monthly Pension (SMP). You fill in the first part. A medical examiner then records what you can do in a typical day and where you need help.

Living in a nursing home? VA's pension guidance says nursing-home applicants also need Form 21-0779, which the nursing home completes. Fill in Form 21-0779.

Parts someone else completes

The examiner completes Sections VI to VIII (items 16 to 45), including the diagnoses, the help needed with daily activities, and the examiner's signature. The form says the examiner must be a medical doctor (MD), doctor of osteopathic medicine (DO), physician assistant or advanced practice registered nurse. A relative can share what they see, but should not fill in the clinical section.

What you fill in by hand

The filler never asks for your Social Security number, VA file number, date of birth or signature. You write those in by hand. Leave these boxes for yourself:

• Items 2 and 7: Social Security numbers (and the SSN line at the top of pages 2, 3 and 4)
• Item 3: VA file number
• Item 4: veteran's service number
• Items 5 and 9: dates of birth
• Item 11: international phone number
• Items 15A and 15B: signature and date
• Items 16 to 45

Where to send it

• First take the form to an eligible examiner (MD, DO, physician assistant or advanced practice registered nurse) to complete items 16 to 45. Before you leave, check that the examiner answered the questions and signed.
• Online: VA's form page links to its online aid and attendance application.
• Pension or survivor benefits by mail: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.
• A veteran's compensation claim by mail: Claims Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. Keep the exam with the claim or evidence it supports.
• If VA sent you a letter asking for this form, follow its instructions. Keep a copy of the completed report and your receipt.

Claim Raven does not submit forms to VA. You review the filled PDF, sign and date it, and send it to VA yourself. Claim Raven is independent and is not affiliated with VA.

Official form and guide

• VA's page for Form 21-2680 on VA.gov
• VA Form 21-2680 example and how to fill it out

This filler uses the June 2026 edition of the form.