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U n i t e d I f MailingStates:Completed Form From the M a n

UnitedIf MailingStates:Completed Form From the

ManilaU.S. PSCFPO DepartmentRegional 501AP 96515-1100 Officeof Veterans Affairs

Places:If Mailing Completed Form From All Other

1131U.S. 0930 DepartmentRoxas Manila Blvd.of Philippines Veterans Affairs

All Other 1 1 3 1 U . S . 0930 DepartmentRoxas Manila B l v
All Other 1 1 3 1 U . S . 0930 DepartmentRoxas Manila B l v

STATEMENT IN SUPPORT OF CLAIM (Filipino Veterans Equity Compensation Fund)

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FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

SOCIAL SECURITY NO.

VA FILE NO.

C/CSS -

The am following applying statement for a one-time is made payment in connection from with the a Filpino claim for Veterans benefits in Equity the case Compensation of the above-named Fund as veteran: a honorably discharged veteran who served, before July

1, 1946, in the organized military forces of the Government of the Commonwealth of the Philippines, including certain service in the Philippine Scouts or

in organized guerrilla forces recognized by the United States Army, while such forces were in the service of the Armed Forces of the United States.

I

I served in:

I served in: Commonwealth Army Recognized Guerilla New Philippine Scouts Date of Birth: Place of Birth:

Commonwealth Army

I served in: Commonwealth Army Recognized Guerilla New Philippine Scouts Date of Birth: Place of Birth:

Recognized Guerilla

I served in: Commonwealth Army Recognized Guerilla New Philippine Scouts Date of Birth: Place of Birth:

New Philippine Scouts

Date of Birth:

Place of Birth:

Service Number:

Unit in Which Served:

 

Dates of Service:

From:

To:

Father’s Name:

Mother’s Name:

Name of Current Spouse:

Date of Marriage:

Spouse’s Date of Birth:

Address(If current differentof address): Currentfrom veteran’sSpouse

PVAO(If applicable)Account Number:

I Am a U.S. Citizen:

PVAO (If applicable) Account Number: I Am a U.S. Citizen: YES NO U.S. Passport No.: IMPORTANT

YES

(If applicable) Account Number: I Am a U.S. Citizen: YES NO U.S. Passport No.: IMPORTANT Affairs

NO

U.S. Passport No.:

IMPORTANT Affairs must receive - Use this this form form only on or with before claims February under 16, the 2010, Filipino to Veterans consider Equity your claim Compensation for this benefit. Fund. The Department of Veterans

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

SIGNATURE

DATE SIGNED

ADDRESS

TELEPHONE NUMBERS (Include Area Code)

DAYTIME

EVENING

PENALTY:knowing it toThebe false.law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,

VAFEBFORM2009

21-4138(CF)