| Name: __________________________________________________________________________________________________________________ | ||
| Address: ____________________ ____________________________________________________________________________________________ | ||
| City: __________________________________________ | State: ______________________________ | Zip: _____________ |
| Phone Number: __________________________________ | Fax Number: _________________________ | |
| Email Address: ___________________________________________________________________________________________ | ||
| Social Security Number: ___________________________ | Claim Number: __________________________ | |
Are you in the V.A. system now? yes: ________ no: ________ Do you have a claim in the system now? yes: ________ no: ________ What month and year were you in Korea? month: ______ year: ______ Do you have a service connected disability now? yes: ________ no: ________ Are you being treated by the V.A. now:? yes: ________ no: ________ Are you being treated for P.T.S.D. at the V.A? yes: ________ no: ________ Are you being treated by a private doctor for war related injuries now or at any time in the past? Yes: ________ no: ________
Write any comment that will help with this claim: ___________________________________________________________________________ _______________________________________________________________________________________________________________________
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