VA Claims Intake Form

I acknowledge I have been made aware of the policies and procedures of the VAC of Macoupin County that apply to the assistance I am seeking — including the Financial Assistance Program Policy (MACVAC-VS-001) and the VAC's intake and assistance procedures — and understand it is my responsibility to read them. *

I authorize the VAC of Macoupin County to verify and, where necessary, share information about my eligibility with other agencies for the purpose of determining benefits and assistance. I certify the information I provide is true to the best of my knowledge. *

I consent to my signature being kept on file and used as a digital signature for future claim forms or documents (optional — you may instead sign each document individually).

Preferred type of contact

Marital Status

Optional Demographic Info

Service Type (check all that apply)

War Era (check all that apply)

Spouse

Dependent Children

If you wish to file an increase you will be required to sign a waiver.

New medical conditions you wish to claim

Toxic Exposure & Service History (check all that may apply — these can make a condition presumptive)

Deployments & Duty Locations (list all — most Veterans have several)