Application Information and Instructions for VA Form 21-0304

General Information

Spina Bifida Benefits Eligibility

Children of Women Vietnam Veterans Born with Certain Birth Defects - 38 U.S.C. 1815

If achievement of a vocational goal is reasonably feasible, a program of vocational training provided by VA's Vocational

Rehabilitation and Employment Service is available to an eligible child.

The law allows health care covering the defects or any disability associated with the birth defects. This care may be provided directly

or by contract.

Health Coverage:

Vocational Rehabilitation:

Monetary Allowance:

Mail the Completed Form To:

Completion of VA Form 21-0304, Application for Benefits for a Qualifying Veteran's Child Born with Disabilities, is required. The effective date is

December 1, 2001.

The law does not include conditions that are:

APPLICATION INFORMATION AND INSTRUCTIONS FOR VA FORM 21-0304

• be the biological child of a woman veteran who served in the Republic of Vietnam (RVN),

• have been conceived after the date the veteran first served in the RVN during the period 2/28/61 to 5/7/75, and

• have certain birth defects identified by the Secretary of Veterans Affairs as resulting in permanent physical or mental disability.

• a familial disorder,

• a birth-related injury, or

• a fetal or neonatal infirmity with well-established causes.

• be the biological child of a veteran who served in the RVN and was exposed,

• have been conceived after the date the veteran first served in the RVN during the period 1/9/62 and 5/7/75, and

• have any type of spina bifida other than spina bifida occulta. The diagnosis may be established by private physicians, or government or private

institution examination reports.

• be the biological child of a veteran who served in or near the DMZ in Korea, and was exposed,

• have been conceived after the date the veteran served in or near the DMZ in Korea during the period 9/1/67 to 8/31/71, and

• have any type of spina bifida other than spina bifida occulta. The diagnosis may be established by private physicians, or government or private

institution examination reports.

Please read information and instructions before completing attached application.

VA FORM 21-0304, MAR 2023

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To be eligible, the child must:

This section of the law authorizes the payment of monetary benefits to, or on behalf of, certain children of female veterans who served in Vietnam.

Benefits are payable to qualifying children, or on their behalf, beginning December 1, 2001. There are three eligibility requirements.

Monetary benefits may be paid to, or on behalf of, children of veterans who served in the RVN.

To be eligible for monetary benefits, the child must:

The law does not allow payment of both benefits at the same time. If entitlement exists under both laws, benefits will be paid

under 38 U.S.C. 1815.

Possible Entitlement:

The law includes levels of monetary allowance, each based on the level of disability of the eligible child.

Department of Veterans Affairs

Evidence Intake Center

P.O. Box 4444

Janesville, WI 53547-4444

38 U.S.C. 1805: Vietnam

38 U.S.C. 1821: Korea

Monetary benefits may be paid to, or on behalf of, children of veterans who served in or near the demilitarized zone (DMZ) in Korea.

38 U.S.C. 1822: Thailand

Monetary benefits may be paid to, or on behalf of, children of veterans who served in Thailand.

• be the biological child of a veteran who served in Thailand at any United States or Royal Thai base, including any United States or Royal Thai bases on

the coast of Thailand, and was exposed,

• have been conceived after the date the veteran served in Thailand during the period 1/9/62 to 6/30/76, and

• have any type of spina bifida other than spina bifida occulta. The diagnosis may be established by private physicians, or government or private

institution examination reports.

To be eligible for monetary benefits, the child must:

IMPORTANT -

Note:

SECTION I: CHILD'S IDENTIFICATION INFORMATION

SECTION II: RELATIONSHIP WITH PARENTS

J. PROVIDE THE DATES THAT PARENT 2 WAS IN VIETNAM, THAILAND, OR

KOREA

8. NAME(S), ADDRESS, TELEPHONE NUMBERS, AND VETERAN STATUS OF NATURAL PARENT(S)

(Please provide information for both parents)

APPLICATION FOR BENEFITS FOR A QUALIFYING VETERAN'S

CHILD BORN WITH DISABILITIES

OMB Approved: 2900-0572

Respondent Burden: 10 minutes

Expiration Date: 03/31/2026

VA FORM

MAR 2023

21-0304

1. NAME OF CHILD (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER OF CHILD (Required)

5. CHILD'S PLACE OF BIRTH (City and State, County and State, or City and Country)

7. CHILD'S MAILING ADDRESS (Number and Street or Rural Route, P.O. Box, City, State, ZIP Code and Country)

6. TELEPHONE NUMBER OF CHILD (Include Area Code)

B. NAME OF PARENT 2 (First, Middle Initial, Last)A. NAME OF PARENT 1 (First, Middle Initial, Last)

9A. SOCIAL SECURITY NUMBER (SSN) OF PARENT 1

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G. VIETNAM, THAILAND, OR KOREA SERVICE OF PARENT 1

(If "Yes," provide dates in 8J)

C. ADDRESS OF PARENT 1 (Number and Street or Rural Route, P.O. Box, City,

State, ZIP Code and Country)

TO (MM/DD/YYYY):

(If "Yes," provide dates in 8I)

FROM (MM/DD/YYYY): FROM (MM/DD/YYYY):TO (MM/DD/YYYY):

SUPERSEDES VA FORM 21-0304, FEB 2020.

YES NO

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

Before completing this form, read the Privacy Act and Respondent Burden on page 4. Use this form

to determine your eligibility for benefits for children with certain disabilities who are born of Vietnam veterans or certain

Thailand or Korea service veterans. For more information, you can contact us online through Ask VA: https://ask.va.gov/

or call us toll-free at 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms. After completing the

form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.

You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of

the form.

3. CHILD'S DATE OF BIRTH (MM/DD/YYYY)

YearDayMonth

No. &

Street

Apt./Unit Number City

ZIP Code/Postal Code State/Province Country

D. ADDRESS OF PARENT 2 (Number and Street or Rural Route, P.O. Box, City,

State, ZIP Code and Country)

E. TELEPHONE NUMBER OF PARENT 1 (Include Area Code) F. TELEPHONE NUMBER OF PARENT 2 (Include Area Code)

H. VIETNAM, THAILAND, OR KOREA SERVICE OF PARENT 2

9B. SOCIAL SECURITY NUMBER (SSN) OF PARENT 2

9C. VA CLAIM NUMBER OF PARENT 1

(If applied previously) 9D. VA CLAIM NUMBER OF PARENT 2 (If applied previously)

I. PROVIDE THE DATES THAT PARENT 1 WAS IN VIETNAM, THAILAND, OR

KOREA

4. HAVE YOU PROVIDED A COPY OF THE CHILD'S BIRTH CERTIFICATE TO VA? (If "No," or unsure, attach a copy of the birth certificate with this form)

PROVIDED BIRTH CERTIFICATE WITH THIS FORM PREVIOUSLY PROVIDED BIRTH CERTIFICATE TO VA

INSTRUCTIONS:

NOTE:

YES NO

SECTION IV: DIRECT DEPOSIT INFORMATION

SECTION III: CLAIM INFORMATION

A. HAS THE CHILD BEEN DECLARED INCOMPETENT?

(If "Yes," complete Items 11B and 11C)

B. NAME AND ADDRESS OF THE COURT THAT MADE THE FINDING OF INCOMPETENCY C. NAME AND ADDRESS OF CUSTODIAN/GUARDIAN

12A. DISABILITIES CLAIMED

13A. NAME OF PRIMARY HEALTH CARE PROVIDER

12B. NAME AND PLACE FIRST DIAGNOSED

12C. DATE FIRST DIAGNOSED

(MM/DD/YYYY)

14B. DATE(S) OF TREATMENT (MM/DD/YYYY)

14A. NAME(S) AND PLACE(S) OF MOST RECENT TREATMENT

The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in direct

deposit, provide the information requested below, and attach either a voided personal check or a deposit slip. If you do not have a bank account, please visit

https://www.benefits.va.gov/benefits/banking.asp. This website provides information about the Veterans Benefits Banking Program (VBBP), and a link to banks and

credit unions that may fit your needs. You may also call 1-800-827-1000. If you elect not to enroll, you must contact representatives handling waiver requests for the

Department of the Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any questions or concerns you may have.

16A. ACCOUNT NUMBER (Check only one box and provide the account number)

16C. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the bottom left of your check)

VA FORM 21-0304, MAR 2023

10. IF CHILD IS UNDER AGE 18 & CUSTODIAN/GUARDIAN IS OTHER THAN NATURAL PARENT (Complete Items 10A, 10B, 10C, & 10D)

B. RELATIONSHIP TO CHILD C. ADDRESS OF CUSTODIAN/GUARDIAN OF CHILD

ADOPTIVE PARENT GUARDIAN

OTHER (Specify)

A. NAME OF CUSTODIAN/GUARDIAN OF CHILD

11. IF CHILD IS AGE 18 OR OLDER (Complete Items 11A, 11B & 11C, if applicable)

13B. ADDRESS OF PRIMARY HEALTH CARE PROVIDER

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15. BY CHECKING THE BOX I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT (NOTE: If

you check this box you may skip to Section V)

Account No.:

16B. NAME OF FINANCIAL INSTITUTION (Provide the name of the bank where you want your direct deposit)

CHECKING SAVINGS

D. HAVE YOU PROVIDED A COPY OF THE DECREE OF ADOPTION OR ADOPTIVE PLACEMENT AGREEMENT TO VA? (If "No," or unsure, please attach a copy of

the decree of adoption or adoptive placement agreement with this form)

PROVIDED DECREE OF ADOPTION OR ADOPTIVE PLACEMENT AGREEEMENT WITH THIS FORM

PREVIOUSLY PROVIDED A DECREE OF ADOPTION OR ADOPTIVE PLACEMENT AGREEMENT TO VA

YES NO

SECTION VI: WITNESSES TO SIGNATURE

SECTION VII: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE

(NOTE: REQUIRED ONLY IF ITEM 17A IS BLANK)

SECTION V: CLAIM CERTIFICATIONS AND SIGNATURES

I/WE, the undersigned, hereby authorize the hospital OR physician shown in Items 12B, 13A and 14A to disclose and release to the Department of Veterans Affairs

any information that may have been obtained in connection with the physical examination or treatment of the child.

I/WE, the undersigned, declare under penalty of perjury that the information provided is true and correct and that the child named in Item 1 is the natural child of the

person(s) named in Items 7A and/or 7B.

19A. SIGNATURE OF WITNESS (Sign in ink. If adult child or parent or custodian/guardian

signed above using an "X")

19B. PRINTED NAME AND ADDRESS OF WITNESS

17A. SIGNATURE OF ADULT CHILD OR PARENT OR CUSTODIAN/GUARDIAN

17B. DATE SIGNED

(MM/DD/YYYY)

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VA FORM 21-0304, MAR 2023

The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,

knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.

20A. ALTERNATE SIGNER SIGNATURE (REQUIRED) (Sign in ink)

I certify that by signing on behalf of the claimant, that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on behalf of a claimant

under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a spouse or other relative; OR, a manager

or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND, that the claimant is under the age of 18; OR, is mentally

incompetent to provide substantially accurate information needed to complete the form, or to certify that the statements made on the form are true and complete; OR, is

physically unable to sign this form.

I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that VA may request

further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant if necessary. Examples of evidence

which VA may request include: Social Security number (SSN) or Taxpayer Identification Number (TIN); a certificate or order from a court with competent jurisdiction

showing your authority to act for the claimant with a judge's signature and a date/time stamp; copy of documentation showing appointment of fiduciary; durable power

of attorney showing the name and signature of the claimant and your authority as attorney in fact or agent; health care power of attorney, affidavit or notarized

statement from an institution or person responsible for the care of the claimant indicating the capacity or responsibility of care provided; or any other documentation

showing such authorization.

20B. DATE SIGNED (MM/DD/YYYY)

18B. PRINTED NAME AND ADDRESS OF WITNESS

18A. SIGNATURE OF WITNESS

(Sign in ink. If adult child or parent or custodian/guardian

signed above using an "X")

PENALTY:

VA will not disclose the information collected on this form to any source other than what has been authorized under the Privacy

Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or

research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs

and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation,

Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is required in order to obtain

or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 U.S.C. 5101 (c) (1). The VA will

not deny an individual benefit for refusing to provide your SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975,

and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the purpose of determining your

eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the

Department of Veterans Affairs.

PRIVACY ACT INFORMATION:

RESPONDENT BURDEN: We need this information to determine your eligibility for benefits for children with certain disabilities who are born of Vietnam veterans

or certain Thailand or Korea service veterans (38 U.S.C. chapter 18). Title 38, United States Code, allows us to ask for this information. We estimate that you will need

an average of 10 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a

valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can

be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments

or suggestions about this form.

YearDayMonth

17C. PRINTED NAME OF PERSON SIGNING ITEM 17A

YearDayMonth