Centralized Intake Coversheet
USE THIS COVER SHEET TO SEND CLAIM MATERIALS TO THE VA CLAIMS INTAKE CENTER
*** EFFECTIVE JANUARY 2017 – PLEASE DO NOT USE PREVIOUS VERSIONS***
Centralized Intake Coversheet
To: Department of Veterans Affairs Claims Intake Center
PO BOX 4444, Janesville, WI 53547-4444
Fax:844-531-7818
Claimant Last Name:
Claimant First Name:
Claimant C-File #:
Claimant Zip Code:
VSO Contact Email:
Fax Date (MM/DD/YYYY – if applicable):
# of Pages to Include Coversheet:
Emergent Claim Categories (if applicable)
TERM
"TERM" Terminally ill claimants
FPOW
"FPOW" Former prisoners of war and their survivors
AGE
"AGE" Greater than 85 years of age
SERW
"SERW" Veterans seriously injured in service but not in receipt of beneu001fts
HOME
"HOME" Homeless Veterans
HONR
"HONR" Awarded the Medal of Honor
FINH
"FINH" Claimants suffering from extreme financial hardship
SUIC
"SUIC" Suicidal claimants
Visually Impaired Veteran
Visually Impaired Veteran
ALS
"ALS" Diagnose with Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s Disease
List Forms Included:
00381
00381 VA 21-0781 Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD)
00142
00142 VA 21-674 Request for Approval of School Attendance
00295
00295 VA 21-22 Appointment of Veterans Serv. Org.
00148
00148 VA 21-686c Declaration of Status of Dependents
00111
00111 VA 21-2680 Request for Aid and Attendance / Housebound Status
00158
00158 VA 21-8940 Veteran's Application for Increased Compensation Based of Unemployability
00115
00115 VA 21-4138 Statement In Support of Claim
00173
00173 VA 572 Request for Change of Address / Cancellation
00386
00386 VA 21-4140-1 Employment Questionnaire
00420
00420 DD 214 Certiu001fed Original - Certiu001fcate of Release
00131
00131 VA 21-526 Veterans Application for Compensation
00025
00025 Birth Certiu001fcate
00532
00532 VA 21-526b, Veteran Supplemental Claim
00091
00091 Divorce Decree
00533
00533 VA 21-526EZ, Fully Developed Claim (Compensation)
00061
00061 Marriage Certiu001fcate / License
Other
Other:
Other (List)
IMPORTANT: Verify on Fax Confirmation Sheet the Claims Evidence is sent to
844-531-7818
7818Disclaimer: VA Directive 6609, “Mailing of Sensitive Personal Information,” dated May 20, 2011 states that access to Veterans’ records is limited to authorized persons only. Information may not be disclosed from this file unless permitted by all applicable legal authorities, enforced by 38 C.F.R. §§ 1.460 – 1.599 and 45 C.F.R. Parts 160 and 164. The Privacy Act contains provisions for criminal penalties for knowingly and willfully disclosing information from the Veterans’ file unless properly authorized to do so.
IMPORTANT: Verify on Fax Confirmation Sheet the Claims Evidence is sent to
844-531-7818
7818Disclaimer: VA Directive 6609, “Mailing of Sensitive Personal Information,” dated May 20, 2011 states that access to Veterans’ records is limited to authorized persons only. Information may not be disclosed from this file unless permitted by all applicable legal authorities, enforced by 38 C.F.R. §§ 1.460 – 1.599 and 45 C.F.R. Parts 160 and 164. The Privacy Act contains provisions for criminal penalties for knowingly and willfully disclosing information from the Veterans’ file unless properly authorized to do so.