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n

’ 1 ’ . 5 ‘ OMB Comro| No_ 2900-0001 ‘1
' Respondem Burden: l hour
Expiration Dare: 8/31/2017

VETERAN'S APPL|CAT|CSN FOR COMPENSAT|O_N AND/OR PENS|ON

 

   

 

100 NoT leTE m THls sPA¢E)
1vA DATE sTAMP)

 

 

1. FOR WHAT BENEF_lT ARE You APPLY|NG? 4
§- coMPENSAT»loN § PENsloN § BOTH co_MPéNSATlON AND PENSloN

 

2 HAVE YOU PREV|OUSLY APPLIED FOR ANV VA BENEF|T(S) ? (( /mkapplicab/e hu.x)

§ PENSloN § coMPENSATloN § oTHER(Specify)

 

 

3. F|R’STl M|DDLE, LAST NAME OF VETERAN

w .n._

4A. VETERAN'S SOC|AL SECUR!TY NO. 4B. VA F|LE NUMBER ([/`a/)p/i¢~ab/e) 4C. SPOUSE'S SOC\AL SECUR|TY NO.`

 

 

 

 

4D. lF YOU SERVE_D U[\JD§R ANOTHER NAME, G|VE NAME AND PER|OD DUR|NG WHlCH YOU.»SERVED A`ND SERV|CE NO.

 

 

5. MA|L|NG ADDRESS (N11111/1e1' and .\‘Ireel ar rural rr)u/¢.'. c/'Iy ur l’.()., Slale and le’ ('.'r)de)

 

6 TELEPHONE NUMBER(S) (lnc/udu Area(_. ade) 7-.‘E-MA\_LADDRESS_(l/`£lpp/ic‘ab/€)
A. DAYT|ME B EVEN|NG C CELL

 

 

 

 

aA. DATE OF BlRTH 11140,111,, day year/ eB. PLACE oF BlRTH .' 9. sE><
4 1 , - . 1 `. § MALE § FEMALE

10A' HAVE YOU EVER F|LED A CLA!M FOR COMPENSAT|ON FROM 1OB. WHEN WAS THE CLA|M F|LED? 1OC. EOR WHAT DlSAB|LlTY ARE YOU
THE oFFlcE oF WORKERS' coMPENsAT10N PROGRAMS? W”~ d”y- .v'-/ ' _RECE'V'NG BENEF'TS?
(l"r)rmer/y /lw l/..S`. Bureau Qf`l;'n_1[)l0yee.\' Compenmlion) _ . af

§ YES {:] NO' a (If "Yes. " cbn1}1/ete ltems ]0B & /()C)

 

 

 

 

 

 

 

11 PLEASE PROV‘DE NATURE OF SICKNESS. D|SEASE OR |NJUR|ES FOR WH|CH TH|S CLA|M lS MADE; DATE i:ACH BEGAN; AND PLACE OF TREATN|ENT

 

 

 

 

 

 

 

 

 

 

 

 

 

A. LIST DlSABlLlTY(lES) ` B. DATE BEGAN C. PLACE OF TREATMENT
* 12A ARE You NOW oR HAVE You REcE\vED -` 123 DATES oF TREATMENT/cARE 120. NAME.AND ADDRESS 0F vA MED|CAL FAC|L|TY
TREATMENT OR DOM|C|LIARY CARE AT A VA . 1 ' (]fy()u need more .\'pace use llem 45, "l\’emark.\")
MEDacAL FAclL\TY? M°""' Day' _ Ye~a' ‘
§ YEs` § No (1f"Yes,"comp/e1e lzem; 1213 &12C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13A'. HAVE YOU EVER BEEN A PR|SONE_ER OF WAR? - 135. NAME QF COUNTRY ' ' 13C, DATE_S OF CONF|NEMENT 1
w - "" ` FRoM . _ 10
[:] YES m NO (l/ Ye.\' comp/ere /Iem.\' I.JB ami l3() . 4 ` n _ 14 ~ 0
14 ARE YOU CLA\M|NG A D|SAB|L|TY RELATED TO AGENT ORANGE OR ' _` _ 15. ARE YOU CLA|MlNG A DlSABlLlT_Y RELATED TO ASBESTOS
OTHER HERB|C|DE EXPOSURE'? (l_/ "Ye.\,"/1\(di.\11/)iliL\1(ic.s) helrm) ' l EXPOSURE? (I_/ "Ye.\'. "11\1 disabllily(ies) be/ou)
§YES§NO ` "§YES§NO
16 ARE YOU CLA|M|NG A DiSAB|L|TY RELATED TO MUSTARD GAS EXFOSURE? 17. ARE YOU CLA|M|NG A D|SAB|L|TY RELATED TO |ON|Z|NG RAD|AT|ON
(l_/ "Yc.\ "liv/ dl.\ab/I/`/y(iu\) hclm¢) EXPOSURE'? (l/"YL'A',"/i.vldi.vabiliL\/(ie.§) hel¢)w)
§YES§NO ._ _ §YE_s'§ No __ ,__.,., w .
18. ARE YOU CLA|M\NG A D|SAB|L\TY RELATED TO AN ENVIRONMENTAL HAZARD EXPOSURE DUR|NG THE GULF WAR? (If'"Yc.\', " /1'.\'1 di.\'abili/y(ies) bela\v)
§ YEs § No
‘ YOU MUST SlGN AND PR|NT YOUR NAME AND DATE TH|S FORM lN lTEMS 42A THRU 420 ON PAGE 10.
VA FORM SUPERSEDES VA FORM 21-526, JUN 2014.
Nov 2014 21'526

WH|CH W|LL NOT BE USED. PAGE 5

 

5
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j(§\»§j‘ 4 1a

 

 

28A. DATE AND PLACE OF MARRlAGE

 

MONTH, YEAR_ C|TY.v STATE

ZBC. TERM|NATED

28D, DATE AND PLA_CE TERM|NATED

 

(Death, Divorce)

MONTH, YEAR

C|TY, STATE

 

 

 

 

 

FURN|SH THE FOLLOWlNG |NFORN|ATION ABOUT EACH PREVIOUS MARR|AGE

OF YOUR PRESENT SPOUSE (IFNOTAPPLICABLE, WR]TE "N/A ’)

 

29A, DATE AND PLACE OF MARR!AGE

 

MONTH. YEAR ClTY. STATE '

2954 To WHOM MARR\ED

290_ TERM|NATED `

290. DATE AND PLACE TERM|NATED

 

(Dearh, Divorce)

MONTH, YEAR

C|TY, STATE

 

 

 

 

 

 

 

 

DEPENDENCY~ Dependenf Children lnformation (Ifyou need additional space, use Item 45 "Remarks")

 

FURN|SH\THE FOLLOW|NG lNFORMAT|ON FOR EACH OF YOUR DEPENDENT CH|LDREN

 

SOB. DATE & PLACE OF
BlRTH
(City, state or country)

3OA. NAME OF CH|LD
{First, middle ini!ia/, ]asl)

 

SOC. SOC|AL SECUR|TY
NUMBER

eloLoGchL

300. CHECK EACH APPL|CABLE CATEGORY

ADOPTED STEPCH|LD

16-23 YR`ST sERlous`LY cHlLD
oL,p AND lN DISABLED PREvlousl_Y
scHooL BEFORE AGE1s MARR|ED

 

(Month, day, year)

Place:

E ¢

El []

, ;l:]

E

[]

 

(Month, day, year)

Place;

 

(Mo`m‘h, day, year)

 

Place:

 

' 11

[] |:l

 

 

 

i:]

ij

 

 

[]

 

FURNISH THE FOLLOVV|NG |NFORMATION FOR EACH OF YOUR DEPENDENT CH|LDREN VVHO DO NOT LlVE W|TH YOU

 

31A. NAME(s) oF ANY cHlLD(REN) NoT
lN YouR cusToDY

3184 NAME AND ADDRESS OF
_ PERSON HAVING CUSTODY

31C. MONTHLY AMOUNT YOU

CONTR|BUTE TO
CHILD'S SUPPORT

 

 

 

 

 

NOT:E You do not have to submit medical evidence or list disabilities if you~are age 65 or older unless you are housebound or require
the regular assistance of another person.

 

32. WHAT DlSAB|L|TlES PREVENT YOU FROM WORKING? (List below)

 

[:] YES

|:]NO

33. DO YOU NEED THE REGULAR ASS|STANCE OF ANOTHER PERSON OR ARE
YOU GENERALLY CONF|NED TO YOUR IMMED|ATE PREM|SES?

 

NURS|NG HOME |NFOR|V|AT|_ON

 

NOTE: You may submit a statement by an official of the nursing home that tells us that you‘ are a patient in the nursing home because of a physical or
mental disability The statement should include the monthly charge you are paying out-of-pocket fo_r your care.

 

34A. ARE YOU NOW |N A NURS|NG HOME?

(lf "YES,"comp/e!e
|:) YEs m NO new 3431hr1/34D)

 

34B. NAME AND CON\PLETE MA|L|NG ADDRESS CF THE FACiLlTY

MED|CA|D'?

[:] YES |:]No

 

34C. HAVE YOU APPL|ED FOR

 

HOME COSTS OR HAVE YOU APPL|ED AND NOT
RECEIVED A DEC|S|ON?

[:| YES |:]No

34D. DOES MED|CAID COVER ALL OR PART OF YOUR NURS|NG»

[:] APPL\ED - NoT REcElon DEclsloN

 

34E ARE YOU RECE|V|NG _SUPPLEMENTAL SOC|AL SECUR|TY |NCOME (SSI)
OR HAVE YOU APPL|ED FOR SSI BUT NO DEClS|ON HAS BEEN MADE?

[] YES [:] No :] APPL|ED NOT REcEivED DEclsloN

 

 

ti’>"

YOU MUST S|GN AND PRINT YOUR NAME AND DATE TH|S FORM |N-lTEMS_ 42A THRU 420 ON PAGE 10.

 

PAGE 7

 

State Counsel for Offenders

Texas Depart_ment of Criminal Justice
P O. Box 4005
- Huntsvi||e,TX 77342-4005
' (936) 437-5203

May12,2_015

lJoseph Ceaser
TDCJ ID#. 19_4.4()45
Estelle Unit (E2/032)

Dear Mr. Ceaser:

We recently received your letter asking for assistance with sex registration; The ]'" able of
Contents in Chapter 8 in Volurne 1 of the State Counsel for Offenders Legal Handbook contains
general information

Since sex registration is a paiole (and 11 ec World legal issue), you must obtain the assistance ot
an outside attorney that practices in this area of law You can find addresses 1n the Texas Legal
Directory (Blue Books).

Both the Legal Handbook and the Blue Books are in the unit law library. The law librarian can
assist you in finding the information referenced herein.

L&\M O§u\im.n_, ref D<M\§td(;;d Mww ear

"M“»l WQ,S.»~Y §‘am Qa~al‘a uaw
BUM indem 7);., `T_§`°'§ l%

 

Legai services :ll:o ma ge …1 PR@:}@J lime irene l.c,,s\.»»L&-le&»
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cc:File ' .¢ . ._
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NO l`E: Please complete the information for each period ofactive duty Attach DD2l4 or other separation papers for all periods ol`active duty lfyou do not have
your DD2l4 form or other separation papers check the box |:\

 

19A: ENTEl?;ED lNTO SERV|CE 195. SERV|CE 19C. SEPARATED FROM SERV|CE ~ i 19D. BRANCH OF 19E. GRADE, RANK OR
` NUMBER SERV|CE . RATlNG, ORGANlZAT|ON

 

 

 

DATE PLACE DATE ' PLACE

 

 

 

 

 

 

 

 

 

 

 

NOTE: Enter complete information for each period of Reserves and National Guard service Attach any separation papers you have.-

 

 

 

 

 

 

 

 

 

 

 

 

20A. ENTERED 1Nr0 sEvacE _ 205. sEercE zoc_ sEPARArED Fr=_zorvr sEvaeE S::';b:ET€Y'_?F' zoE. GRADE, RANK on
` , NuMBER ` _ (_"""“ RAT|NG, oRGAleATlON
DATE PLACE ` DATE PLACE N“"“"“' ""”"/}
_/’ "_ "_" .
21 rF DrsAeiLiTY occuRRED DuRiNG AcrivE oR 1NAcT1vE 22A ARE You Novv A MEMBER oF THE RESERVES 223 RESERVE STATUS
ourv FoR rRAerNG GrvE BRANCH oF sERvicE AND DATE on NATroNAL GUARD? rF so erer _THE BRANCH l:| ACT,VE l:| RESERVE
oF occuRRENcE 01= sERvicE _ ostreAnoN
t [:| _YES |:] NO BRANCH [| inAcrl\/_E

 

 

 

 

22C. NAME, ADDRESS AND PHONE NO_. OF RESERVE OR NAT|QNAL GUARD UN|T (I_/`au'dilir)na/ space i.\' needed, u.vu llem`,45 "Remark.s"')

 

lMPORTANT » Unless you check the box in item 25 below, you are telling us that you are choosing to receive VA compensation instead of military retired pay, if
it is determined you are entitled to both benei'rts. ll you are awarded military retired pay prior to eompensation, we will reduce yo'u`r retired pay by the amount of any
compensation'that you are awarded VA will,notify the Military Retired Pay Center of all benefit changes lf you receive both military retired pay and VA
compensation, some ot" the amount you receive may be recouped by VA` or, in the case of Voluntary Separation l`ricentive (VSI), by the Depanment of_Defense.

 

 

 

 

 

 

23A. ARE YOU RECE|V|NG MiLlTARY 23B. W|LL YOU RECEi\/E MILITARY RET|RED PAY lN THE 230- BRANCH OF 230. MONTHLY
RET|RED PAY? (lf "Yes, "complele FUTURE? ([f ")'es, "éxp/ain, i.e, Fu_ture Reserve/National Guard - SERV|CE AMOQNT
ltems 23C & 23D) Retiremenl, }’ending MEB/PEB) '
g YEs l:l No ij YEs_ [:l No $
241 RET|RED STATUS 25. NO, l DO NOT WANT VA COMPENSAT|ON lN LlEU OF M|L|TARY RET|RED PAY'
l:l RETrRED m TEMPORARY DlsABlLiTY [:] DlsABLED (Check box.'ifapplicable) l:]
RETIRED LlST RET|RED LlST

 

 

  

'26 HAVE YOU EVER APPL|ED FOR OR RECE|VED DlSABlL|TY SEVERANCE/SEPARAT|ON PAY OR AN_Y OTHE_R LUMF SUM PAY|V|ENT FROM THE ARMED
FORCES? (l_/ "YL'\. "ll\'l type alm)rurl dale il \111.\' rcc¢.'i\ezl. mull/w branch uf .\cri ice hc/r)\r')

|:| YEs m No-

 

     

27A MAR|TAL STATUS (l_/ married c()/np/ele ]Ienl.\' 2 7/1‘ lhru 29/))

. 27a sPouSES'S BlRTHDATE (M11.. 11¢1,11._111.)
E] MARR|ED [:] WlDoWED l:| DlvO_RcED ' |:] NEVER MARRiED(//111»11)11111111111/, 1111/1111/1€11131)) " '-

 

 

 

27€1. NUMBER OF T|_MES 27D~ NUMBER OF T"V|ES YOUR 27E. IS,¥OUR SPOUSE ALSO A VETERAN? '27F. SPOUSE'S VA F|LE NUMBER (Ifany)

YOU HAVE BEEN PRESENT SPOUSE H.AS ' - . ` -

MARRlED (l`u include ..BEEN MARR!ED (7`0 l:' YES l: NO (lf"Yes, "comp/ete '. '

CW"¢"" ”'””"”XL’) include current marriage) l - ' '[lem 2 7}")

. _ ~ " C-
27G. DO YOU LlVE TOGETHER? 27H. REASON FOR SEPARATION (l"r)r example`, __ - 27|y PRESENT ADDRE$S OF SpOUSE
' niarila/ proh/cm.\'.jr)b ruqr/il'uniul1l.r, hea/Ih, elc`,) ' ,)_.

|:’ YES |:} NO (lf "No, "comp/ele llems_27H thru 27./) w

 

 

 

27.1. AMOUNT ¥OU CONTR\BUTE TO YOUR 271< HOW WERE YOU MARR;ED')

SPOUSE'$ MONTHLY SuPPORT |:| CLERGYMAN OR AUTHOR,ZED l:] TR|BAL I:| OTHER (EXp/am)
PuBch oFFicrAl_

[:| coMMON-LAW |:] PROXY

 

 

 

YOU MUST S|GN AND PR|NT YOUR NAME AND DATE TH|S FORM |N |TEMS.42A THRU 42C ON‘PAGE 10.

 

 

 

PAGE 6

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