**CHAPTER 17. CLAIMS DEVELOPMENT PROCESSING**

**CONTENTS**

PARAGRAPH PAGE

**SUBCHAPTER I. GENERAL PROCEDURES**

17.01 General 17-I-1

17.02 Development Screens 17-I-1

17.03 CDEV Procedures 17-I-1

**SUBCHAPTER II. SERVICE RECORDS REQUESTS**

17.04 3101 Data Selection - The 201 Screen 17-II-1

17.05 Request for Military/Medical Data - The 202 Screen 17-II-3

**SUBCHAPTER III. GENERAL DATA REQUESTS**

17.06 General Claimant Data - The 203 Screen 17-III-1

**SUBCHAPTER IV. DEPENDENCY REQUESTS**

17.07 Dependency Data - The 204 Screen 17-IV-1

**SUBCHAPTER V. BURIAL DATA REQUESTS**

17.08 Burial Reimbursement Data - The 206 Screen 17-V-1

**SUBCHAPTER VI. DISABILITY/DEATH REQUESTS**

17.09 Disability/Death Claim Letters - The 208 Screen 17-VI-1

**SUBCHAPTER VII. MISCELLANEOUS LETTERS/FREE TEXT**

17.10 Miscellaneous Letters - The 209 Screen 17-VII-1

17.11 Free Text Screen - The 290 Screen 17-VII-4

**CHAPTER 17. CLAIMS DEVELOPMENT PROCESSING**

**SUBCHAPTER I. GENERAL PROCEDURES**

**17.01 GENERAL**

With the CDEV command, additional information for a claim may be
requested by instructing the system to send appropriate evidence request
letters to claimants, the service departments and to other third party
sources. Completing a 200-level screen establishes a development segment
in the PIF until the evidence request is generated during end-of-day
processing. If an award is GAP\'d on the same day, the development
paragraphs generated by entries on screens other than the 208 or 209 are
held in the PIF until the award letter is generated.

**17.02 DEVELOPMENT SCREENS**

The screens available under the CDEV command are the 200-series screens.
The screens available for C&P processing under CDEV are:

a\. 201 - 3101 Data Selection

b\. 202 - Request for Military/Medical Data

c\. 203 - General Claimant Data

d\. 204 - Dependency Data

e\. 206 - Burial/Reimbursement Data

f\. 208 - Disability/Death Claim Letters

g\. 209 - Miscellaneous Letters

**17.03 CDEV Procedures**

a\. The minimum entries on the Ready Screen are:

\(1\) The command, CDEV.

\(2\) Operator\'s password.

\(3\) Screen number (optional).

\(4\) File number.

b\. Upon entry of a properly completed Ready Screen, the 200 Screen
specified will be displayed.

c\. If a specific screen was not requested on the Ready Screen, the 200
Development Screen Selection Screen will be displayed. Select the
desired screen number and enter it in the NEXT SCREEN field to continue
processing.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

200 DEVELOPMENT SCREEN SELECTION XX-XX-XX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX-XXXX NAME X X XXXXX

201 3101 DATA SELECTION

202 REQUEST FOR MILITARY/MEDICAL DATA

203 GENERAL CLAIMANT DATA

204 DEPENDENCY DATA

205 EDUCATION

206 BURIAL/REIMBURSEMENT DATA

207 VOCATIONAL REHABILITATION AND COUNSELING

208 DISABILITY/DEATH CLAIM LETTERS

209 MISCELLANEOUS LETTERS

S99 DISPOSITION

NEXT SCREEN XXX

Figure 17.01. DEVELOPMENT SCREEN SELECTION - 200 SCREEN LAYOUT

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

d\. If an exact pending issue was not specified on the Ready Screen and
more than one pending issue is found, the S02 Selection Screen is
displayed. Select the applicable issue by making a positive entry in the
space to the left of the desired issue.

**SUBCHAPTER II. SERVICE RECORDS REQUESTS**

**17.04 3101 DATA SELECTION - THE 201 SCREEN**

a\. **General.** The 201 Screen, 3101 DATA SELECTION, is used to request
information from a service department using VA Form 21-3101-3, Veterans
Administration Request for Information, which is transmitted
electronically.

b\. **Screen Access.** The 201 Screen is accessed by entry of the
command, password, screen number and file number on the Ready Screen. If
a pending issue is found, the 201 Screen will be displayed with the File
Number, Payee Number, End-Product Code and Stub Name displayed from the
PIF with any pertinent data obtained from the BIRLS record.

c\. **Screen Completion.** The following describes the 201 Screen and
the proper entries for each field.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

201 3101 DATA SELECTION XX-XX-XX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX XXXX NAME X X XXXXX

CLAIM LEGEND

X DISABILITY X DEATH X BURIAL X NATIONAL GUARD X RESERVE

X EDUCATION X UNEMPLOYMENT X DEATH IN SVC X LOANS

X PENSION X SERVICE PENSION X BODY HELD X SGLI

X DENTAL X HOSPITALIZATION X DOMICILIARY VA INS NO

X INS WAIVER X INS CLAIM X INS APPLICATION XXXXXXXXX

TYPE CLAIM/REQUEST: ADDRESS CODE SVC XXX MEDICAL XX

X ORIGINAL BRANCH OF SERVICE XXXX

SECOND REQUEST XXXXXXXX SEPARATION FORMS ON FILE X

DATA REQUESTED:

X SERVICE X MEDICAL X DENTAL X CLINICAL X OTHER

SVC NAME XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX SSN XXXXXXXXXXX

AKA XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

BIRTH PLACE XXXXXXXXXXXXXXXXXXXXXX DOB XXXXXXXX DOD XXXXXXXX

RESERVE STATUS: X NONE X UNKNOWN RES OBLIG DATE XXXXXXXX

RETIRED STATUS: X IN PAY X NON PAY X TDRL

NEXT SCREEN XXX

Figure 17.02. 3101 DATA SELECTION - 201 SCREEN LAYOUT

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

\(1\) **CLAIM LEGEND.** Use this area to indicate the nature of the
pending claim. There are a total of 19 fields; enter an X in at least
one of these.

\(a\) **For CPL Claims.** Specify at least one but no more than three:

DISABILITY SERVICE PENSION

PENSION HOSPITALIZATION

DENTAL DOMICILIARY

UNEMPLOYMENT LOANS

SGLI

\(b\) **For CPD Claims.** Enter only one of the following:

DEATH

BURIAL

DEATH IN SVC

BODY HELD

\(c\) **Insurance Fields.** Only one of the following may be entered (a
selection may also be made in a CPD field);

INS WAIVER

INS CLAIM

INS APPLICATION

VA INS NO

\(d\) **NATIONAL GUARD.** If entered, an entry is required in either a
CPL or CPD field.

\(e\) **RESERVE.** If entered, an entry is required in a CPL or CPD
field. If entered on a death claim, DEATH or BURIAL must also be
entered.

\(2\) **TYPE CLAIM/REQUEST**

\(a\) **ORIGINAL.** Entry in this field is required and indicates if
this is an original request. For original requests, enter Y; for
supplemental requests, N.

\(b\) **SECOND REQUEST.** Enter this field if a supplemental request is
being sent. Enter the date the original request was completed using any
acceptable date format. If the exact day of the original entry is
unknown, the days position may be 00.

\(3\) **ADDRESS CODE.** This field indicates the address code to which
the request is being directed. Entry in this field is optional. If left
blank, the system will use the Branch of Service, Reserve Status,
Retired Status, Pay Grade and last entered RAD date to generate the
appropriate address code.

\(a\) **SVC.** Enter the valid address code as shown in part III,
chapter 4.

\(b\) **MEDICAL.** Enter the valid address code. Use this field only for
NAVY and only when requesting both service and medical information from
different address codes.

\(4\) **BRANCH OF SERVICE.** If not displayed from BIRLS, entry in this
field is required and must be compatible with the address code entered.
Enter the branch of service from which evidence is to be requested.
Valid entries are:

ARMY or A

NAVY or N

AF

M

CG

MM

\(5\) **SEPARATION FORMS ON FILE.** Entry indicates whether or not the
DD214 or equivalent is contained in the file. If not displayed from
BIRLS, entry is required. Valid entries are Y and N.

\(6\) **DATA REQUESTED.** Entry is required in at least one but not more
than three of the subfields. If OTHER is entered, the NEXT SCREEN entry
**MUST** be 202.

\(a\) **Service.** The only valid entry is X.

\(b\) **Medical.** The only valid entry is X.

\(c\) **Dental.** The only valid entry is X.

\(d\) **Clinical.** The only valid entry is X.

\(e\) **Other.** The only valid entry is X.

\(7\) **SERVICE NAME.** Entry is required if not displayed from the
BIRLS record. The minimum entry is two alpha characters separated by a
space. Entry format is last name, first name, middle initial. Do **NOT**
use spaces between names.

\(8\) **SSN.** Enter the Social Security number of the veteran if not
displayed. The format should be NNN-NN-NNNN or NNN NN NNNN. The first
digit cannot be 6, 8 or 9. No segment can be all zeroes, i.e.,
000-NN-NNNN, NNN-00-NNNN or NNN-NN-0000.

\(9\) **AKA.** This field is protected from entry.

\(10\) **BIRTH PLACE.** Enter the city and state of veteran\'s birth.

\(11\) **DOB.** Enter the veteran\'s date of birth in acceptable date
format.

\(12\) **DOD.** Enter the veteran\'s date of death in any acceptable
date format. Entry is required for CPD claims.

\(13\) **RESERVE STATUS.** An entry in one of the three subfields is
required if RETIRED STATUS is not entered.

\(a\) **NONE.** The only valid entry is X indicating the veteran has no
Reserve obligation.

\(b\) **UNKNOWN.** The only valid entry is X indicating obligation
status is unknown.

\(c\) **RES OBLIG DATE.** Entry indicates the veteran has a Reserve
obligation that ends on the date entered. Standard date edits will be
applied to entry.

\(14\) **RETIRED STATUS.** An entry in one of these three fields
indicates the veteran retired from the military. An entry is required if
RESERVE STATUS is not entered. The only valid entry is X.

\(15\) **NEXT SCREEN.** Screen 202 is automatically displayed in this
field, but END, DEL or S99 may be entered to override the 202 entry.
When S99 or END is entered, the PIF is updated and control is
transferred to disposition processing. When DEL is entered, all screen
entries are deleted from the pending issue.

**17.05 REQUEST FOR MILITARY/MEDICAL DATA - THE 202 SCREEN**

a\. **General.** The 202 Screen is used in conjunction with data entered
on the 201 Screen to request information from a service department.

b\. **Access.** The 202 Screen may be accessed only from the 201 Screen.
Upon successful entry of the 201 Screen with 202 in the NEXT SCREEN
field, the 202 Screen will be displayed with File Number, Payee Number,
End-Product Code and Stub Name with any pertinent information obtained
from the BIRLS file or data entered on the 201 Screen.

c\. **Screen Completion.** The following describes the fields contained
on this screen and the valid usage and entry requirements.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

202 REQUEST FOR MILITARY/MEDICAL DATA XXXXXXXX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX XXXX NAME X X XXXXX

EOD RAD DISCH SERVICE NO GRADE ORGANIZATION SEPFORM

XXXXXXXX XXXXXXXX XXX XXXXXXXX XXXX XXXXXXXXXX XXX

XXXXXXXX XXXXXXXX XXX XXXXXXXX XXXX XXXXXXXXXX XXX

XXXXXXXX XXXXXXXX XXX XXXXXXXX XXXXXXXXXX XXX

CONDITION TREATMENT DATES PLACE TYPE

XXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXX XXXXXXXXX XXXX

XXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXX XXXXXXXXX XXXX

XXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXX XXXXXXXXX XXXX

SPECIAL INFORMATION

X DD 214 X VERIFY SVC X ADDL SVC X CONS OBJECTOR

X TRAVEL TIME X SEV/READJ X TDRL X ACDUTRA

X PHYSICAL EOD X PHYSICAL RAD X X-RAYS X PURPLE HEART

X PAY GRADE X CASUALTY REPORT X 90 DAY CERT X MARITAL DATA

X LAST RANK/ORG X PERS DESCRIPTION POW STATUS XX-XX-XX XX-XX-XX

CHAR DISCH INFO XX-XX-XX COND DISCH XX-XX-XX COMPLETE SEPARATION
XX-XX-XX

x CIV TRNG X SVC ACAD X SVC SCH X CHAP 35 SVC X DEL ENT PROG

ADDITIONAL INFORMATION

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

NEXT SCREEN XXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Figure 17.03. REQUEST FOR MILITARY/MEDICAL DATA - 202 SCREEN LAYOUT

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\(1\) **EOD.** Entry is required if not displayed from BIRLS and SEP
FORM display is YES. Entry must be in an acceptable date format.

\(2\) **RAD.** Entry is required if not displayed from BIRLS and SEP
FORM display is YES. Entry must be in an acceptable date format.

\(3\) **DISCH.** Entry is required if not displayed from BIRLS or if
EOD/RAD are entered. Valid entries are: UNV, HON, OTH, DIS.

\(4\) **SERVICE NO.** Entry is required if not displayed from BIRLS and
SEPFORM is YES.

\(5\) **GRADE.** Entry is required if not displayed from BIRLS and
SEPFORM is YES. Valid entries are:

O-XX where XX = 1 through 10

W-XX where XX = 1 through 5

E-XX where XX = 1 through 10

\(6\) **ORGANIZATION.** Entry is required if YES is displayed in
SEPFORM. Minimum entry is two alpha characters separated by a space.

\(7\) **SEPFORM.** Allowable entries are Y, YES, N and NO. If entry is Y
or YES, an entry in RAD is required.

**NOTE:** Three lines of data may be entered.

\(8\) **CONDITION.** Each row must be completed sequentially. Enter the
condition for which treatment was rendered.

\(9\) **TREATMENT DATES.** Entry is required if CONDITION is entered on
the same line. Enter dates in any acceptable date format (00 may be used
for days position if exact day is unknown).

\(10\) **PLACE.** Entry is required if CONDITION is entered.

\(11\) **TYPE.** Entry is required if CONDITION is entered. Valid
entries are HOSP, OPC and OTH.

**NOTE:** Three lines are provided in this section.

\(12\) **SPECIAL INFORMATION.** Valid entries are X, Y and dates, if
applicable. Dates may be entered in any acceptable date format; 00 may
be entered for day position if exact day is unknown.

\(13\) **ADDITIONAL INFORMATION.** If data required are not listed
elsewhere on this screen, enter the data request in this field.

\(14\) **NEXT SCREEN.** Valid entries are DEL, END, S99 or other
200-series screen.

d\. **Additional Information.** If an X or date is entered in any fields
under SPECIAL INFORMATION, a paragraph or statement is printed on the
3101 form in the additional information block. Data entered in the
ADDITIONAL INFORMATION field are also printed in this area. The form has
only 11 available lines. If the messages requested will exceed 11 lines,
the form cannot be generated. In these cases, the message REQUEST INFO
EXCEEDS PRINT CAPABILITY - PREPARE MANUAL REQ will be displayed to alert
the operator.

e\. **Legends.** The legends printed for entries in SPECIAL INFORMATION
section are:

**FIELD ENTERED** **STATEMENT PRINTED ON REQUEST**

DD 214 Copy of any separation documents

VERIFY SVC Complete verification of service

ADDL SVC Verification of any additional service

CONS OBJECTOR Statement of nature of release as a conscientious
objector, indicating whether based on refusal to perform military
service, refusal to wear the uniform or noncompliance with lawful orders
of competent military authorities

TRAVELTIME Certification of traveltime - PL 87-102

SEV/READJ Verification of receipt of Severance or Readjustment Pay,
including

type and amount

TDRL Verification of receipt of Disability Severance Pay, including

amount and date

ACDUTRA Verification if any service was ACDUTRA. If so, furnish dates
and branches of service

PHYSICAL EOD Copy of physical exam at induction

PHYSICAL RAD Copy of physical exam at discharge

X-RAYS All chest films at induction and separation

PURPLE HEART Verification of receipt of Purple Heart, including the date
and disability for which awarded

PAY GRADE Certification of highest pay grade held for 6 months or longer

CASUALTY REPORT Copy of casualty report or statement as to date military
pay terminated, including any beneficiary(ies) on pay and allowance

90 DAY CERT Verification of 90 days active service

MARITAL DATA Marital status, name and address of spouse or next of kin
given by veteran at time of entrance into last period of active service

LAST RANK/ORG Last rank or grade and organization

PERS DESCRIPTION Personal description, including marks and scars,
height, complexion, color of hair and eyes

POW STATUS Verification of POW status from MM-DD-YY to MM-DD-YY and
clinical records for repatriation

CHAR DISCH INFO Facts and circumstances of OTH discharge on MM-DD-YY,
including records of courts-martial, punishment under Article 15 UCMJ
and Board of Officers proceedings

COND DISCH Was the veteran eligible for complete separation prior to
MM-DD-YY? If not, state date(s) when this individual completed the
period(s) of active service for which he/she was obligated at the
time(s) of induction or reenlistment(s)

COMPLETE SEPARATION Eligibility for complete separation on MM-DD-YY

CIV TRNG Beginning and ending dates of any periods in which education or
training was pursued full-time at a civilian school. Include the name of
the school and courses pursued

SVC ACAD Furnish beginning and ending dates of any attendance at one of
the service academies in cadet or midshipman status and the name of the
academy

SVC SCH Furnish beginning and ending dates and place of education or
training received at any military service school. Include the name of
any course or training pursued

CHAP 35 SVC Verify above service dates in support of claim for
Dependents\' Educational Assistance under Chapter 35.

DEL ENT PROG Verify whether the individual entered military service
under the provisions of the Delayed Enlistment Program (DEP) or other
program of delayed entry (e.g., ROTC, PLC, AFHPSP, AVROC I). If so,
furnish the date the DEP contract or other agreement was entered into

f\. **PIF Update.** On successful completion of the 202 Screen, the PIF
is updated and processing continues as indicated by the NEXT SCREEN
entry. After the 3101 request has been transmitted to the service
department, the 201/202 segment is deleted from the PIF.

**SUBCHAPTER III. GENERAL DATA REQUESTS**

**17.06 GENERAL CLAIMANT DATA - THE 203 SCREEN**

a\. **General.** Use the 203 Screen to request income, disability and
service information from a claimant. During processing, some fields will
be protected from entry for certain payee/benefit type combinations,
e.g., in the PIF of a CPL claim with payee 00, entry in the DEATH
CERTIFICATE field is prohibited.

b\. **Screen Completion.** The following describes the fields appearing
on this screen and the allowable entries for each field.

[                                                                              ]{.underline}

203 GENERAL CLAIMANT DATA XX-XX-XX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX XXXX NAME X X XXXXX

INCOME DATA

X IMPROVED X SPOUSE ANNUAL INCOME XXXXXXXX TO XXXXXXXX

X OLD LAW X CHILD(REN) XXXXXXXX TO XXXXXXXX

X 306

X DIC

X 527 X 526 X 8049-GENERAL EXPENSES X SS AWARD LETTER

X BUSINESS/RENTAL X 8049-LAST EXPENSES X RET/ANNUITY LETTER

X FARMING/INCOME X 8049-INSURANCE X SICK/WORKER-UNEMPLOY COMP

X FAMILY MED EXPENSE-FROM XXXXXXXX TO XXXXXXXX X WAGES

X ELECTION NOTICE X HARDSHIP EXPENSES

DISABILITY/DEATH DATA

X 4142 X X DEATH CERTIFICATE X A/A MEDICAL EVIDENCE

X A/A NURSING HOME X HOUSEBOUND X RECENT TREATMENT

X TREATMENT VA FACILITY X ACCIDENT/INJ XXXXX X NATURE OF DISABILITY

X PRIOR TREATMENT X DATE LAST WORKED X TREATMENT SINCE DISCHARGE

X CURRENT EMPLOYMENT X POW STATUS X A/A SPOUSE

X HOSPITAL/DOCTOR REPORT: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

X TREATMENT FOR: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

X SERVICE RECORDS X MEDICAL RECORDS NEXT SCREEN XXX

Figure 17.04. GENERAL CLAIMANT DATA - 203 SCREEN LAYOUT

[                                                                             ]{.underline}

c\. **INCOME DATA Fields.** Use the following fields to request
information about the claimant\'s income and expenses.

\(1\) **EVR TYPE - IMPROVED OLD LAW 306 DIC**

\(a\) An entry in one of these fields determines the EVR or income form
that is to sent to the claimant. Only one of the four fields can be
entered. Enter X in the appropriate field.

\(b\) If IMPROVED is entered, the payee number must be 00, 10-19 or
31-39 **AND** ANNUAL INCOME must be entered.

\(c\) If OLD LAW or 306 is entered, the payee number must be 00, 10-19
or 31-39.

\(d\) If entry is made in DIC, the payee number must be 50 or 60.

\(2\) **DEPENDENCY - SPOUSE CHILD(REN)**

\(a\) Use these fields to further indicate the type of EVR form to be
sent to the claimant. Enter X to indicate the dependents in this claim.

\(b\) If SPOUSE is entered, the payee number must be 00.

\(c\) If CHILD(REN) is entered, the payee must be 00 or 10.

\(d\) If payee number is 11-19 or 31-39 both SPOUSE and CHILD(REN) must
be blank.

\(3\) **ANNUAL INCOME XXXXXXXX TO XXXXXXXX.** Enter the month, day and
year the income report is to begin and end. Two periods may be entered.
This field can only be used when IMPROVED is entered.

\(a\) The dates entered on one line cannot be greater than 1 year in
duration.

\(b\) The FROM date cannot be more than 2 years in the past. For
example, if the current date if 5-16-92, this date cannot be earlier
than 05-16-90.

\(c\) The TO date cannot be more than 2 years in the future.

\(d\) If both lines are entered, the dates on the second line must be
contiguous with those on the first line.

\(4\) **527.** Enter X to show claimant is to complete and return VA
Form 21-527.

\(5\) **526.** Enter X to show claimant is to complete and return VA
Form 21-526.

\(6\) **8049 - General Expenses.** Enter X to request a complete report
of current expenses.

\(7\) **SS AWARD LETTER.** Use this field to request a copy of the
Social Security award letter showing the effective date and rate. Enter
P for payee\'s letter, S for spouse\'s letter, B for payee and spouse
letters, C for children\'s letters, or F for all the family\'s letters.

\(8\) **BUSINESS/RENTAL.** Enter X in this field to transmit VA Form
21-4185 for business or rental income information.

\(9\) **8049 - LAST EXPENSES.** Enter X in this field to send VA Form
21-8049 with request for information on expenses of last illness and
burial.

\(10\) **RET/ANNUITY LETTER.** Use this field to request a copy of the
retirement or annuity award letter. Enter P to request information for
the payee, S for spouse or B for both.

\(11\) **FARMING/INCOME.** Enter X to request a statement about farming
activity.

\(12\) **8049 - INSURANCE.** Enter X to request data on the amount of
commercial insurance the claimant has received or expects to receive.

\(13\) **SICK/WORKER-UNEMPLOY COMP.** Enter X to request a statement
from the claimant as to receipt of sick benefits or workmens\'
compensation to include the beginning date, rate and termination date.

\(14\) **FAMILY MED EXPENSE-FROM XXXXXXXX TO XXXXXXXX.** Enter X in this
field to request the total unreimbursed medical expenses for the payee
and dependents, to include premiums for insurance. If entry is made in
the indicator field, entry is also required in the FROM and TO date
fields. Enter the dates in any valid date format including month, day
and year.

\(a\) The dates entered cannot be greater than 2 years in duration.

\(b\) The FROM date cannot be more than 2 years in the past. For
example, if the current date is 5-16-92, this date cannot be earlier
than 05-16-90.

\(c\) The TO date cannot be more than 2 years in the future.

\(15\) **WAGES.** Enter X to request the amount of severance pay,
vacation pay or accrued wages received from the last employer.

\(16\) **ELECTION NOTICE.** Enter X to advise veteran of the need for an
election of Improved Pension prior to increased payment.

\(17\) **HARDSHIP EXPENSES.** Enter X to request information from the
claimant on family living expenses that may be used to reduce income of
children for Improved Pension.

d\. **DISABILITY/DEATH DATA Fields**

\(1\) **4142.** Enter X to enclose a form for the claimant to authorize
release of treatment records from a non-VA facility. Two forms are
enclosed when the indicator is entered. If you wish to send more than 2
forms, enter the appropriate number (3-9) in the space to the right.

\(2\) **DEATH CERTIFICATE.** Enter X to request a copy of the veteran\'s
death certificate.

\(3\) **A/A MEDICAL EVIDENCE.** Enter X to request a doctor\'s statement
about the claimant\'s need for A&A to include diagnosis, limitations and
prognosis. If it is entered, A/A NURSING HOME and HOUSEBOUND cannot be
entered.

\(4\) **A/A NURSING HOME.** Enter X to request a statement from the
nursing home director to include the date of admission and level of
care. If it is entered, A/A MEDICAL EVIDENCE and HOUSEBOUND cannot be
entered.

\(5\) **HOUSEBOUND.** Enter X to request a statement from doctor about
Housebound status. If entered, A/A MEDICAL EVIDENCE and A/A NURSING HOME
cannot be entered.

\(6\) **RECENT TREATMENT.** Enter X to request information about
treatment for the claimed disabilities within the last 3 months
including the name and address of the doctors or hospitals providing the
care.

\(7\) **TREATMENT VA FACILITY.** Enter X to request information about
treatment at VA expense.

\(8\) **ACCIDENT/INJ.** Enter X to request information on VA Form
21-4176 about the accident or injury occurring on the date entered. To
the right of the field legend enter the date of accident or injury in
month-year format.

\(9\) **NATURE OF DISABILITY.** Enter X to request a statement as to the
nature of the illness, disease or injury for which benefits are claimed.

\(10\) **PRIOR TREATMENT.** Enter X to request a statement about
disabilities treated prior to service.

\(11\) **DATE LAST WORKED.** Enter X to request the month, day and year
of last employment.

\(12\) **TREATMENT SINCE DISCHARGE.** Enter X to request evidence that
the claimed disabilities were treated since discharge.

\(13\) **CURRENT EMPLOYMENT.** Enter X to request information about the
type of work, number of hours and earnings of current job.

\(14\) **POW STATUS.** Enter X to request the dates and places of
confinement as a POW.

\(15\) **A/A SPOUSE.** Enter X to request a doctor\'s statement on
spouse\'s need for A&A. Entry permitted only if payee is 00 and benefit
type is CPL.

\(16\) **HOSPITAL/DOCTOR REPORT**

\(a\) Enter X to advise claimant a hospital or doctor has failed to
respond to a VA request for evidence and request the claimant assist in
getting the evidence submitted.

\(b\) To the right of the field legend, enter the name of doctor or
hospital from whom or from which evidence was requested.

\(17\) **TREATMENT FOR**

\(a\) Enter X to request information from claimant if the service
department has been unable to locate treatment records.

\(b\) In the field to the right of field legend, enter the disabilities
for which the service department has been unable to locate records of
treatment.

\(18\) **SERVICE RECORDS.** Enter X to request a copy of the veteran\'s
DD214 or equivalent.

\(19\) **MEDICAL RECORDS.** Enter X to request any service medical
records in the claimant\'s possession.

\(20\) **NEXT SCREEN.** Valid entry is any other 200-level screen, DEL,
RES, END or S99.

**SUBCHAPTER IV. DEPENDENCY REQUESTS**

**17.07 DEPENDENCY DATA - THE 204 SCREEN**

a\. **General.** Use the 204 Screen to request information on dependents
claimed by a beneficiary or claimant. Certain fields are protected if
they do not pertain to a particular payee-benefit combination.

b\. **Completion of the 204 Screen.** The following describes the fields
appearing on the screen and the usage and entry requirements of each
field.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

204 DEPENDENCY DATA XX-XX-XX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX XXXX NAME X X XXXXX

MARITAL DATA

PROOF OF DISSOLUTION-PRIOR MARRIAGE X MARRIAGE CERTIFICATE

X CLAIMANT XXXXXXXXXX X COMMON LAW

X SPOUSE XXXXXXXXXX X SEPARATION

X COHABITATION-QUESTIONABLE X APPORTIONMENT

X COHABITATION-NOT INDICATED WITHHOLDING AMOUNT XXX

X DEEMED VALID W/H EFFECTIVE DATE XXXXXXXX

X 686C X 8796 X 4103 PROPOSED EFFECTIVE DATE XXXXXXXX

CHILDREN DATA

X 686C X DATE OF BIRTH X BIRTH RECORD X ADOPTED X STEPCHILD

XXXXXXXXXX XXXXXXXXXX XXXXXXXX XXXXXXXXXX

XXXXXXXXXX XXXXXXXXXX XXXXXXXX XXXXXXXXXX

XXXXXXXXXX XXXXXXXXXX XXXXXXXX XXXXXXXXXX

X 674 X X 674B X X ILLEGITIMATE X CUSTODY X HELPLESS

XXXXXXX XXXXXXX XXXXXXX XXXXXXX XXXXXXX

XXXXXXX XXXXXXX XXXXXXX XXXXXXX XXXXXXX

XXXXXXX XXXXXXX XXXXXXX XXXXXXX XXXXXXX

PARENTAL DATA

X PARENTAL STATUS X ABANDONMENT X SURVIVORS X 509

X VETS BIRTH RECORD X MARITAL STATUS X LOCO PARENTIS NEXT SCREEN XXX

Figure 17.05. DEPENDENCY DATA - 204 SCREEN LAYOUT

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

\(1\) **MARITAL DATA**

\(a\) **PROOF OF DISSOLUTION - PRIOR MARRIAGE**

[1]{.underline}. **CLAIMANT.** Enter X to request a certified copy of
the divorce decrees for prior marriages of the claimant. To the right of
the field legend, enter the names of prior spouses, if available.

[2]{.underline}. **SPOUSE.** Enter X to request a certified copy of
divorce decrees for prior marriages of the spouse. To the right of the
field legend, enter the names of prior spouses, if available.

\(b\) **MARRIAGE CERTIFICATE.** Enter X to request a certified copy of
marriage certificate as proof of the legality of current marriage.

\(c\) **COMMON LAW.** Enter X to request the facts and circumstances
concerning the common law relationship.

\(d\) **SEPARATION.** Enter X to request a statement as to the amount
contributed by the claimant for support and for separated spouse\'s
address.

\(e\) **COHABITATION - QUESTIONABLE.** Enter X to request evidence of
continuous cohabitation from the date of marriage to the date of death.

\(f\) **APPORTIONMENT.** Enter X to request income and expense
information for use in determining dependent\'s need for an
apportionment. If entered, no other field in MARITAL DATA section may be
entered except WITHHOLDING AMOUNT, EFFECTIVE DATE and PROPOSED EFFECTIVE
DATE. Entry is required if one of the three subfields is entered.

[1]{.underline}. **WITHHOLDING AMOUNT.** Entry is required if W/H
EFFECTIVE DATE or PROPOSED EFFECTIVE DATE is entered. If entered,
APPORTIONMENT must be entered. Valid entry is up to three numerics.
Enter the dollar amount to be withheld pending a final determination.

[2]{.underline}. **W/H EFFECTIVE DATE.** Entry is required if entry is
made in WITHHOLDING AMOUNT or PROPOSED EFFECTIVE DATE fields. Entry can
be in any acceptable date format but cannot be earlier than the first of
the current month. Entry provides notification of the date withholding
will begin.

[3]{.underline}. **PROPOSED EFFECTIVE DATE.** Enter the date in any
acceptable date format. Entry is required if entry is made in
WITHHOLDING AMOUNT or W/H EFFECTIVE DATE. This field provides due
process and advises claimant of the date withholding will begin if
apportionment is granted at the end of the predetermination period.

\(g\) **COHABITATION - NOT INDICATED.** Enter X to request evidence of
continuous cohabitation from the date of marriage to the date of death.

\(h\) **DEEMED VALID.** Enter X to request verification that there was
no legal impediment to the marriage and that cohabitation was
continuous.

\(i\) **686C.** Enter X to request completion of VA Form 21-686C.

\(j\) **8796.** Enter X to request a certified copy of the public record
of termination of marriage and completion of VA Form 21-8796.

\(k\) **4103.** Enter X to request information from a remarried
surviving spouse on VA Form 21-4103.

\(2\) **CHILDREN DATA Fields**

\(a\) **686C.** Enter X to request completion of VA Form 21-686C with
dates and places of birth for all children.

\(b\) **DATE OF BIRTH**

[1]{.underline}. Enter X to request child\'s date of birth.

[2]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(c\) **BIRTH RECORD**

[1]{.underline}. Enter X to request a certified copy of the birth
certificate or baptismal certificate.

[2]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(d\) **ADOPTED**

[1]{.underline}. Enter X to request a certified copy of the court order
of adoption or placement.

[2]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(e\) **STEPCHILD**

[1]{.underline}. Enter X to request a certified copy of the birth or
baptismal certificate plus a certificate of marriage between the veteran
and the parent of the child.

[2]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(f\) **674**

[1]{.underline}. Enter X to request completion of VA Form 21-674 for
child(ren) over age 18 attending school.

[2]{.underline}. To the right of the field legend, enter the number of
forms to be sent. Valid entry is 2 through 9.

[3]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(g\) **674b**

[1]{.underline}. Enter X to request completion of VA Form 21-674b within
30 days after the day school commences.

[2]{.underline}. To the right of the field legend, enter the number of
forms to be sent. Valid entry is 2 through 9.

[3]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(h\) **ILLEGITIMATE**

[1]{.underline}. Enter X to request a certified copy of the birth or
baptismal certificate and a statement that the child was a member of the
veteran\'s household at the time of the veteran\'s death.

[2]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(i\) **CUSTODY**

[1]{.underline}. Enter X to request the name and address of the person
having custody.

[2]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(j\) **HELPLESS**

[1]{.underline}. Enter X to request a statement from a physician
regarding the child\'s condition, onset, diagnosis and prognosis.

[2]{.underline}. Enter up to three children\'s names (up to 10
characters each) to limit the request to data for the specified
children. If no names are entered, the request will be issued for data
on EACH CHILD.

\(3\) **PARENTAL DATA Fields**

\(a\) **PARENTAL STATUS.** Enter X to request a statement from the
claimant as to whether benefits are claimed as the natural or foster
parent.

\(b\) **ABANDONMENT.** Enter X to request information needed to
establish if the veteran lived with the claiming parent continuously
until the age of majority.

\(c\) **SURVIVORS.** Enter X to establish if the veteran was survived by
a spouse or children.

\(d\) **509.** Enter X to request completion and return of VA Form
21-509, Parent\'s Income Statement.

\(e\) **VETS BIRTH RECORD.** Enter X to request a copy of the veteran\'s
birth or baptismal record showing the names of both parents.

\(f\) **MARITAL STATUS.** Enter X to request a statement showing the
marital status of the parents.

\(g\) **LOCO PARENTIS.** Enter X to request completion and return of VA
Form 21-524.

\(h\) **NEXT SCREEN.** Valid entry is any other 200-level screen, DEL,
RES, S99 or END.

**SUBCHAPTER V. BURIAL DATA REQUESTS**

**17.08 BURIAL REIMBURSEMENT DATA - THE 206 SCREEN**

a\. **General.** Use the 206 Screen to request data in connection with a
claim for reimbursement of burial expenses.

b\. **Completion of the 206 Screen.** The following describes the fields
found on the screen and the usage and entry requirements of each field.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

206 BURIAL/REIMBURSEMENT DATA XX-XX-XX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX XXXX NAME X X XXXXX

STATEMENT OF TRANSPORTATION CHARGES FROM:

X UNDERTAKER X CLAIMANT

X INITIAL UNDERTAKER X FINAL UNDERTAKER

CONCERNING CHARGES FOR: X ALL TRANSPORTATION EXPENSES

REMOVAL FROM: X HOSPITAL X RAILROAD X AIRPORT

HEARSE TO: X CEMETERY X RAILROAD X AIRPORT

X OUTSIDE SHP\'G CASE X VAULT X SHIPPING PERMIT X EXPLANATION OF PERMIT

X SERVICE RECORD X PROOF OF DEATH

X NON-RECEIPTED FUNERAL BILL X RECEIPTED FUNERAL BILL

X RECEIPTED BILLS X INITIAL UNDERTAKER\'S BILL

X RAILROAD FARE RECEIPT X CEMETERY/PLOT RECEIPT

X AIRLINE FARE RECEIPT X DEATH VA HOSPITAL

X BURIAL NATIONAL CEMETERY X REIMBURSEMENT NON-VA SOURCES

X INSURANCE BENEFICIARY X IDENTIFICATION OF PAYER OF BILL

X OTHERS ENTITLED BY RELATIONSHIP X HEADSTONE RECEIPT X ADDL ENGRAVING

REIMBURSEMENT WAIVER: X OTHER CLAIMANT REIMBURSEMENT

XXXXXXXXXXXXXXXXXXXXXXXXX X LETTERS OF ADMINISTRATION

NEXT SCREEN XXX

Figure 17.06. BURIAL/REIMBURSEMENT DATA - 206 SCREEN LAYOUT

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

\(1\) **STATEMENT OF TRANSPORTATION CHARGES FROM**

\(a\) **UNDERTAKER.** Enter X to request a statement of charges incurred
by the sole undertaker in transporting the veteran\'s body.

\(b\) **CLAIMANT.** Enter X to request a statement of charges incurred
by the claimant in transporting the veteran\'s body.

\(c\) **INITIAL UNDERTAKER.** Enter X to request a statement of charges
incurred by the undertaker at the place of death in transporting the
veteran\'s body.

\(d\) **FINAL UNDERTAKER.** Enter X to request a statement of charges
incurred by the undertaker at the place of burial in transporting the
veteran\'s body.

**NOTE:** Only one of the four fields shown above may be completed.

\(2\) **CONCERNING CHARGES FOR**

\(a\) **ALL TRANSPORTATION EXPENSES.** If entered, no other entries in
this section are permitted. Enter X to request a statement of expenses
incurred in removal of remains, use of a hearse, outside shipping case,
vault or shipping permit.

\(b\) **REMOVAL FROM**

[1]{.underline}. **HOSPITAL.** Enter X to request the charges for
removal of the remains from the hospital.

[2]{.underline}. **RAILROAD.** Enter X to request charges for removal of
the remains from the railroad station.

[3]{.underline}. **AIRPORT.** Enter X to request charges for removal of
the remains from the airport.

\(c\) **HEARSE TO**

[1]{.underline}. **CEMETERY.** Enter X to request charges for the hearse
to the cemetery.

[2]{.underline}. **RAILROAD.** Enter X to request charges for the hearse
to the railroad station.

[3]{.underline}. **AIRPORT.** Enter X to request charges for the hearse
to the airport.

\(d\) **OUTSIDE SHIPPING CASE.** Enter X to request information on
charges for the outside shipping case.

\(e\) **VAULT.** Enter X to request information concerning charges for
the vault with an explanation if it was used as a shipping case in
addition to use as a burial container.

\(f\) **SHIPPING PERMIT.** Enter X to request information concerning
charges for the shipping permit.

\(g\) **EXPLANATION OF PERMIT.** Enter X to request information
concerning charges for the permit shown on funeral bill with explanation
concerning its use.

\(3\) **SERVICE RECORD.** Enter X to request a copy of the deceased
veteran\'s DD214 or a statement furnishing all available data concerning
his or her service.

\(4\) **PROOF OF DEATH.** Enter X to request a certified copy of the
public record of death.

\(5\) **NON-RECEIPTED FUNERAL BILL.** Enter X to request a funeral bill
showing the name of the deceased, nature and cost of services and all
credits.

\(6\) **RECEIPTED FUNERAL BILL.** Enter X to request a receipted funeral
bill showing the name of the person for whom services were performed and
name of the person from whom payments were received.

\(7\) **RECEIPTED BILLS.** Enter X to request copies of bills showing
payment has been made to all creditors whose services were rendered in
conjunction with the expenses of last illness and burial.

\(8\) **INITIAL UNDERTAKERS BILL.** Enter X to request receipted bills
of the initial undertaker showing that no charges were made.

\(9\) **RAILROAD FARE RECEIPT.** Enter X to request a receipt from the
ticket agent covering the fare for shipment of the remains.

\(10\) **CEMETERY/PLOT RECEIPT.** Enter X to request a copy of the
cemetery bill showing the name of the person who paid for the charges.

\(11\) **AIRLINE FARE RECEIPT.** Enter X to request a receipt from the
ticket agent covering the fare for shipment of the remains.

\(12\) **DEATH VA HOSPITAL.** Enter X to request charges for
transportation from the VA hospital to the funeral home and from the
funeral home to the cemetery.

\(13\) **BURIAL NATIONAL CEMETERY.** Enter X to request charges for
transportation to the national cemetery.

\(14\) **REIMBURSEMENT NON-VA SOURCES.** Enter X to request information
regarding reimbursement from any source other than VA on VA Form
21-4138.

\(15\) **INSURANCE BENEFICIARY.** Enter X to request information if the
insurance used to pay expenses was paid to the estate or to a designated
beneficiary.

\(16\) **IDENTIFICATION OF PAYER OF BILL.** Enter X to request a
statement over the signature of the funeral director showing the name of
person from whom payment was received.

\(17\) **OTHERS ENTITLED BY RELATIONSHIP.** Enter X to request
information on whether or not the veteran was survived by a spouse or
children.

\(18\) **HEADSTONE RECEIPT.** Enter X to request a receipted headstone
bill showing the name of the person for whom the headstone was furnished
and the name of the person who made the payment.

\(19\) **ADDL ENGRAVING.** Enter X to request a receipted bill for the
additional engraving of the veteran\'s existing stone showing the name
of deceased and the name of person who paid the bill.

\(20\) **REIMBURSEMENT WAIVER.** Used to request VA Form 21-5328 signed
by another person who paid a portion of expenses. Required entry is the
name of the person whose signature is needed. Up to 25 characters can be
entered.

\(21\) **OTHER CLAIMANT REIMBURSEMENT.** Enter X to request a statement
whether or not any other person paid any part of the veteran\'s last
illness or burial expenses.

\(22\) **LETTERS OF ADMINISTRATION.** Enter X to request a current
certified copy of the letters of administration or letters testamentary.

\(23\) **NEXT SCREEN.** Valid entry is any other 200-level series
screen, DEL, RES, S99 or END.

**SUBCHAPTER VI. DISABILITY/DEATH REQUESTS**

**17.09 DISABILITY/DEATH CLAIM LETTERS - THE 208 SCREEN**

a\. **General.** Use the 208 Screen to notify claimants of claim status
or to request information from a third party.

b\. **Completion of the 208 Screen.** The following describes the fields
contained on this screen, their usage and entry requirements.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

208 DISABILITY/DEATH CLAIM LETTERS XX-XX-XCX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX XXXX NAME X X XXXXX

XXXXXXXXXXXXXXXXXXXX FAILURE TO REPORT - VA EXAM-CLAIM

XXXXXXXXXXXXXXXXXXXX X DENIED X DISCONTINUED X REDUCED

XXXXXXXXXXXXXXXXXXXX SPECIAL MONTHLY PENSION DENIED

XXXXXXXXXXXXXXXXXXXX X A&A X HOUSEBOUND

XXXXXXXXXXXXXXXXXXXX REQUEST FOR EVID - SC INC CLAIMED

XXXXXXXXXXXXXXXXXXXX XXXXX XXXXXXXXXXXXXXXXXXXXXXXXX

4192 FROM EMPLOYER

C&C LETTER - SC X HEARING OFFICER FOR XXXXXXXXXXXXXXXXXXXXXXXX

EVIDENCE REVIEWED SSN XXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXX X EVID NOT NEW AND MATERIAL

XXXXXXXXXXXXXXXXXXXXXXXXX X HERBICIDE EXPOSURE

DISABILITY EVALUATED X SC DEATH DENIED

XXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXX EVIDENCE REQUEST BY VA

XXXXXXXXXXXXXXXXXXXXXXXX X SVC X DELAY X VA HOSP

XXXXXXXXXXXXXXXXXXXXXXXX VA EXAM-REV X OR PENDING CLAIM X

XXXXXXXXXXXXXXXXXXXXXXXX X INDIVIDUAL UNEMPLOYABILITY DENIED

XXXXXXXXXXXXXXXXXXXXXXXX

FUTURE EXAM XXXX NEXT SCREEN XXX

Figure 17.07. DISABILITY/DEATH CLAIM LETTERS - THE 208 SCREEN LAYOUT

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

\(1\) **NAME AND ADDRESS.** The name and address will be displayed as
contained in the PIF. If not displayed, it must be entered. If the
letter is to go to someone other than the veteran, press ERASE EOF key
and enter the name and address of recipient in this field.

\(2\) **C&C LETTER - SC**

\(a\) **HEARING OFFICER.** The only valid entry is X. If entered,
EVIDENCE REVIEWED, DISABILITY EVALUATED and FUTURE EXAM must also be
entered. Entry generates statement in letter that the Hearing Officer
reviewed the claim.

\(b\) **EVIDENCE REVIEWED.** Two lines of 30 characters each are
provided for entry of the evidence considered, e.g., VA physical exam of
(date). If entered, DISABILITY EVALUATED and FUTURE EXAM must be
entered.

\(c\) **DISABILITY EVALUATED.** Six lines of 30 characters each are
provided for explanation of the disabilities evaluated. If entered,
EVIDENCE REVIEWED AND FUTURE EXAM must be entered.

\(d\) **FUTURE EXAM.** Valid entry is in MMYY format where MM = 01
through 12 and YY is numeric. Entry must be later than the current month
and year. Entry of NONE is also allowed if appropriate. If entered,
EVIDENCE REVIEWED and DISABILITY EVALUATED must be entered.

\(3\) **FAILURE TO REPORT - VA EXAM-CLAIM**

\(a\) **DENIED.** The only valid entry is X. Entry is prohibited if
DISCONTINUED or REDUCED is entered.

\(b\) **DISCONTINUED.** The only valid entry is X. Entry is prohibited
if DENIED or REDUCED is entered.

\(c\) **REDUCED.** The only valid entry is X. Entry is prohibited if
DENIED or DISCONTINUED is entered.

\(4\) **SPECIAL MONTHLY PENSION DENIED**

\(a\) **A&A.** The only valid entry is X. Concurrent entry in HOUSEBOUND
field is allowed. If only A&A is entered, a notice is generated
explaining the requirements for entitlement to A&A and that this benefit
cannot be granted.

\(b\) **HOUSEBOUND.** The only valid entry is X. Concurrent entry in A&A
is allowed. If only HOUSEBOUND is entered, a notice is generated
explaining the requirements for entitlement to Housebound and that this
benefit cannot be granted.

\(c\) **Dual Denial.** If A&A and HOUSEBOUND are both entered, a notice
is generated explaining requirements for entitlement to both benefits
and that the benefits cannot be granted.

\(5\) **REQUEST FOR EVID - SC INC CLAIMED.** Valid entry is any
alphabetic character with maximum entry of 25 positions. Entry generates
a letter requesting evidence in support of a claim for higher
compensation for an increase in service-connected disability.

\(6\) **4192 FROM EMPLOYER.** This field is used to generate a letter to
the former employer at the address shown in the name and address field
requesting completion and return of VA Form 21-4192.

\(a\) **FOR.** Enter the veteran\'s full name.

\(b\) **SSN.** Enter the veteran\'s Social Security number.

\(7\) **EVID NOT NEW AND MATERIAL.** The only valid entry is X.
Generates notice to claimant that the evidence submitted in support of
claim is basically a duplicate of previous evidence.

\(8\) **HERBICIDE EXPOSURE.** This field is not currently in use.

\(9\) **SC DEATH DENIED.** The only valid entry is X. Entry generates a
paragraph explaining DIC is not payable because service connection
cannot be established for the veteran\'s death.

\(10\) **EVIDENCE REQUESTED BY VA.** These fields are used to
acknowledge receipt of a claim and advise that action is pending receipt
of records as requested.

\(a\) **SVC.** The only valid entry is X to show military records were
requested.

\(b\) **DELAY.** The only valid entry is X. If entered, SVC must be
entered. Advises claimant of delay in obtaining military records.

\(c\) **VA HOSP.** The only valid entry is X. Entry prohibited if DELAY
is entered. Advises records have been requested from a VA hospital.

\(11\) **INDIVIDUAL UNEMPLOYABILITY DENIED.** The only valid entry is X.

\(12\) **NEXT SCREEN.** Valid entries are:

\(a\) **FOR CPL**: 200, 201, 203, 204, 209, 290 or END

\(b\) **FOR CPD**: 200, 201, 203, 206, 209, 290 or END

**SUBCHAPTER VII. MISCELLANEOUS LETTERS/FREE TEXT**

**17.10 MISCELLANEOUS LETTERS - THE 209 SCREEN**

a\. **General.** Use the 209 Screen to generate letters to veterans and
other claimants concerning their claims.

b\. **Completion of the 209 Screen.** The following describes the fields
found on the 209 Screen, their use and entry requirements.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

209 MISCELLANEOUS LETTERS XX-XX-XX

FILE NUMBER XXXXXXXXXXX-XX END PRODUCT XXX XXXX NAME X X XXXXX

XXXXXXXXXXXXXXXXXXXX ELECTION - HIGH SCHOOL

XXXXXXXXXXXXXXXXXXXX DEL DATE EXT - NOT TIMELY FILED

XXXXXXXXXXXXXXXXXXXX DEL DATE EXT - NO QUAL DISABILITY

XXXXXXXXXXXXXXXXXXXX CH32 DEATH REFUND

XXXXXXXXXXXXXXXXXXXX CH32/SEC 903 KICKER

XXXXXXXXXXXXXXXXXXXX XXXXX CH 32/SEC 903 SERVICE REQUIREMENTS

X RETURNED CHECK X APPORTIONMENT DATA - CLAIMANT

XXXXXXXXXXXXXXXXXXXXXXXXX SSN REQUEST X SELF X DEPENDENT

X EVR NOT RETURNED XXXXXXXX X UNEMPLOYABILITY

X OVERPAYMENT X ELECT OF IMPROVED PENSION NOT ADV

ENCLOSE EVR FORM XXXXXXXX MONTHLY RATE IMP PENSION XXX

X 674B NOT RETURNED INITIAL DEATH NOTICE

XXXXXXXXXXXXXXXXXXXXXXXXX X 534 X 535 X ACCRUED AMT PAYABLE

X PENSION WIDOW/ER REMARRIED BURIAL BENEFIT NOTICE

X PTI X PTII X PTIII X PTIV (4103 X BURIAL X PLOT X 601 X 6898

X PENSION WIDOW/ER DECEASED (8919-1) APPEAL: X ORIGINAL X REMAND

X DIC WIDOW/ER REMARRIED (4183)

X DIC WIDOW/ER DECEASED (4183) NEXT SCREEN XXX

Figure 17.08. MISCELLANEOUS LETTERS - THE 209 SCREEN LAYOUT

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

\(1\) **NAME AND ADDRESS.** The name and address will be displayed from
the PIF. If someone other than the addressee shown on initial display is
to receive the letter, press the ERASE EOF key and enter the appropriate
address.

\(2\) **RETURNED CHECK.** The only valid entry is X in the indicator
field. The name field on the following line requires a minimum entry of
two alpha characters. If the indicator or name field is completed, the
other field must also be entered. Entry in this field generates a letter
requesting information about a returned check which was issued to the
person whose name is entered.

\(3\) **EVR NOT RETURNED.** If entered, the indicator, date **AND** one
of the forms **or** OVERPAYMENT must be entered. Entry in this field
generates a letter explaining the termination of VA benefits caused by
nonreturn of the EVR.

\(a\) **INDICATOR.** The only valid entry is X.

\(b\) **DATE.** To the right of the field legend, enter the date of
termination in any acceptable date format.

\(c\) **OVERPAYMENT.** The only valid entry is X.

\(d\) **ENCLOSE EVR FORM.** Valid entries are:

0511S-1

0511V-1

0512S-1

0512V-1

0513-1

0514-1

0516-1

0517-1

0518-1

0519S-1

0519C-1

\(4\) **674B NOT RETURNED**

\(a\) **INDICATOR.** The only valid entry is X. If entered, the child\'s
name must be entered.

\(b\) **NAME.** Minimum entry is two alpha characters. Enter the
child\'s full name.

\(5\) **PENSION WIDOW/ER REMARRIED.** The only valid entry in any part
of this field is X. If the indicator is entered, an entry is required in
at least one of the PT fields. Entry results in a letter asking the
remarried beneficiary to complete part I, II, III or IV of the VA Form
21-4103 for adjustment of benefits.

\(6\) **PENSION WIDOW/ER DECEASED (8919-1).** The only valid entry is X.
Entry produces a letter explaining death pension entitlement for
children of a deceased veteran subsequent to the death of a surviving
spouse.

\(7\) **DIC WIDOW/ER REMARRIED (4183).** The only valid entry is X.
Entry generates a letter explaining DIC entitlement for children of a
deceased veteran subsequent to the remarriage of a surviving spouse.

\(8\) **DIC WIDOW/ER DECEASED.** The only valid entry is X. Generates a
letter explaining DIC entitlement for the children of a deceased veteran
subsequent to the death of a surviving spouse.

\(9\) **ELECTION - HIGH SCHOOL.** The only valid entry is X. Entry
generates a letter explaining the option to elect tuition and fees
rather than a monthly rate.

\(10\) **DEL DATE EXT - NOT TIMELY FILED.** The only valid entry is X.
Entry produces a letter explaining VA\'s inability to extend a
veteran\'s delimiting date when the application was not received within
statutory limits.

\(11\) **DEL DATE EXT - NO QUAL DISABILITY.** The only valid entry is X.
Entry generates a letter denying a claim for extension based on
disability.

\(12\) **CH32 DEATH REFUND.** The only valid entry is X. Entry generates
an award letter to a deceased CH32 veteran\'s survivors informing them
of unused contributions which may be refunded to the estate.

\(13\) **CH32/SEC 903 KICKER.** The only valid entry is X. Entry
generates a letter explaining a pending DOD contribution is not included
in the computed rate.

\(14\) **CH32/SEC 903 SERVICE REQUIREMENTS.** The only valid entry is X.
Entry generates a letter informing the claimant the term of enrollment
begins before his obligated service is completed, and payment will be
withheld until the obligated service request is fulfilled.

\(15\) **APPORTIONMENT DATA - CLAIMANT.** The only valid entry is X. If
the letter is to be sent to someone other than the person shown in the
name and address field, erase the incorrect data and enter the
appropriate name and address. Entry generates a letter requesting income
and expenses in connection with the claim for apportionment of the
veteran\'s benefits.

\(16\) **SSN REQUEST**

\(a\) **SELF.** The only valid entry is X. Entry produces a letter
requesting the Social Security number of the claimant.

\(b\) **DEPENDENT.** The only valid entry is X. Entry produces a letter
requesting Social Security numbers of dependents.

\(c\) **Both.** Both SELF and DEPENDENT may be entered to request
numbers for the claimant and dependents.

\(17\) **UNEMPLOYABILITY.** Enter X in this field to develop claims for
unemployability benefits. VA Form 21-8940 will be issued.

\(18\) **ELECT OF IMPROVED PENSION NOT ADV.** The only valid entry is X.
Entry required if MONTHLY RATE IMP PENSION is entered.

\(19\) **MONTHLY RATE OF IMP PENSION.** Entry required if entry made in
ELECT OF IMPROVED PENSION NOT ADV. Valid entry is one to three numerics
representing the monthly rate of Improved Pension payable (dollars
only).

**NOTE:** Entries in (18) and (19) above generate a letter advising
claimants that an election of Improved Pension is not to their advantage
at this time.

\(20\) **INITIAL DEATH NOTICE**

\(a\) **Indicator.** The only valid entry is X. If entered, 534 or 535
must be entered. Entry generates a letter offering assistance in
obtaining survivor\'s benefits after notice of veteran\'s death.

\(b\) **534.** The only valid entry is X. Encloses VA Form 21-534 in the
above letter. If entered, entry must be made in indicator.

\(c\) **535.** The only valid entry is X. Encloses VA Form 21-535 in the
above letter. If entered, entry is required in indicator field.

\(d\) **Accrued Amt Payable.** The only valid entry is X. If entered, an
entry is required in indicator **AND** either the 534 or 535 field.

\(21\) **BURIAL BENEFIT NOTICE**

\(a\) **Indicator.** The only valid entry is X. If entered, entry is
required in at least one of the four subfields.

\(b\) **Burial.** The only valid entry is X. If entered, entry is
required in the indicator field. Generates a letter explaining
allowances payable for burial expenses.

\(c\) **Plot.** The only valid entry is X. If entered, entry required in
indicator field. Generates a letter explaining allowance for plot
charges when burial is not in a national cemetery.

\(d\) **601.** The only valid entry is X. If entered, entry of indicator
field is required and entry in 6898 cannot be made. Advises claimant of
accrued amount payable.

\(e\) **6898.** The only valid entry is X. If entered, indicator is
required and 601 cannot be entered. Generates an explanation that PFOP
funds may be payable to the person assuming the expenses of last illness
and burial.

**NOTE:** The name and address field may be changed to show the next of
kin or other person as addressee.

\(22\) **APPEAL ORIGINAL REMAND.** Enter X to the left of ORIGINAL to
advise the claimant the appeal is being sent to BVA (Uses the same
language as FL1-26). Enter X to the left of REMAND to advise the
claimant action on the remanded appeal has been completed and the case
is being returned to BVA.

\(23\) **NEXT SCREEN.** Valid entry is any 200-series Screen, RES, DEL,
S99 or END.

**17.11 FREE TEXT SCREEN - THE 290 SCREEN**

a\. **General.** The 290 Screen is used to generate disallowance
letters.

b\. **290 Screen Access.** This screen can only be accessed following
entry of the 405, Disallowance Screen, or the 208, Disability/Death
Claim Letters Screen, meeting the following conditions.

\(1\) The 405 Screen is entered with a reason code other than 04, 16,
19, 21, 22, 29 or 30.

\(2\) The 208 Screen is entered with one of the following fields
completed:

\* Evidence Reviewed

\* Disability Evaluated

\* Failure to Report - VA Exam - Claim Denied

Discontinued Reduced

\* Special Monthly Pension Denied

A&A Housebound

\* Evid Not New And Material

\* SC Death Denied

\* Individual Unemployability Denied

\* Hearing Officer

c\. **Completion of the 290 Screen.** The following describes the fields
found on the 290 Screen, their use and entry requirements.

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

290 FREE TEXT SCREEN XXXXXXXX

FILE NUMBER XXXXXXXXXXXXXX END PRODUCT XXX NAME XXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX \*

ENCLOSURES: XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX

NEXT SCREEN XXX

FIGURE 17.09. FREE TEXT SCREEN - THE 290 SCREEN LAYOUT

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

\(1\) **PIF Data.** The 290 Screen is displayed with the file number,
payee number, end product and stub name displayed from the PIF. No
correction or entry is allowed in these fields.

\(2\) **TEXT LINE.** There are 18 lines available for entry. Each line
allows for entry of 63 alpha numeric characters. The first text line
MUST contain an entry. There can be no more than one blank line between
text. For example, if lines 4 and 7 are entered, lines 5 and 6 cannot
both be blank.

\(3\) **Enclosures.** Entry is restricted to enclosures stocked by the
RDPC. A maximum of three enclosures may be entered. To send multiple
copies of a particular enclosure, the entry should be followed by (N),
where N is the number of copies to be sent, e.g., 21-674B(2). Multiple
copies of 21-0511S-1 through 21-0519-1 cannot be issued. For a list of
acceptable entries, see paragraph 5.09c(12).

\(4\) **Next Screen.** Entry may be any valid processing screen for the
command of entry, RES, DEL or S99.

d\. **Free Text Entry Capability.** When the free text screen is used,
the letter generated to the claimant will contain the information
exactly as entered. The Target system is not a word processor with any
text correction features and does not edit entries, correct grammatical
or spelling errors or change punctuation. The right-hand margin is noted
on the screen by the display of an asterisk (\*). This is a fixed margin
that cannot be changed. All words must end before this symbol or else
the word must be entered on the next line.

e\. **Screen Output.** On successful entry of the 290 Screen, the data
will be stored in the system until the award letter is generated. A
tearsheet will be generated on the local printer. Retain this tearsheet
to document screen content until a copy of the generated letter is
filed.