Jefferson County, NY · Jefferson County
Disability Record Authorization
Veterans complete this authorization to let the Department of Veterans Affairs provide disability-status information to a civil service agency for examination credit.
At a glance
- Issued by
- City of Jefferson County · Jefferson County, Jefferson County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- evogov.s3.amazonaws.com
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form authorizes the Department of Veterans Affairs to provide a civil service agency with information about a veteran’s disability status. The veteran sends two copies to the Department of Veterans Affairs office where the disability claim is on file; the Veterans Benefits Administrator completes the second section and returns the original to the civil service agency. It requests identifying, claim, examination, and disability information.
Who needs it
A veteran claiming examination credit based on disability status completes the first section and authorizes the Department of Veterans Affairs to provide the requested information.
How to submit it
Type or print in ink and send two copies to the Department of Veterans Affairs where your disability claim is on file, addressed to the Chief, Veterans Benefits and Services Division. The administrator returns the original to the civil service agency at the address shown at the top of the form.
About notarization
This document is signed and dated without a notary; the form does not identify any attachment or related step that must be notarized or sworn.
How to submit this form
- 1
Download the Form
Download the Disability Record Authorization to provide permission for disclosure of your disability-status information.
- 2
Complete Section 1
Type or print in ink and provide the requested identifying, claim, examination, and contact information. Sign and date the authorization.
- 3
Prepare Two Copies
Make two copies of the completed form; the document does not list any required attachments.
- 4
Send to Veterans Affairs
Send both copies to the Department of Veterans Affairs where your disability claim is on file, addressed to the Chief, Veterans Benefits and Services Division.
Frequently asked questions
- Do I need a notary for the Disability Record Authorization?
- No. The form asks the veteran to sign and date it, but does not require notarization or identify a notarized or sworn attachment.
- How do I submit the Disability Record Authorization?
- Type or print in ink and send two copies to the Department of Veterans Affairs where your disability claim is on file, addressed to the Chief, Veterans Benefits and Services Division.
- Who completes the Disability Record Authorization?
- The veteran completes Section 1 and sends the form to the Department of Veterans Affairs. A Veterans Benefits Administrator completes Section 2 and returns the original to the civil service agency.