SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO MS Continued If Yes, check all that apply : If Yes, check all that apply : If Yes, check all that.

 

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS Less than once every 2 months Once.

 

4A. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE: 5/5 Normal strength 0/5 No muscle movement 1/5 Visible muscle movement, but no joint movement 2/5 No movement.

 

VA FORM 21-0960C-10, DEC 2010 E. NUMBNESS SECTION IV - NEUROLOGIC EXAM 0/5 No muscle movement 1/5 Visible muscle movement, but no joint movement 2/5 No movement against.

 

If Yes, describe : VA FORM 21-0960C-2, DEC 2010 STRICTURE DISEASE REQUIRING PERIODIC DILATATION EVERY 2 TO 3 MONTHS RECURRENT URINARY TRACT INFECTIONS.

 

VA FORM 21-0960C-11, OCT 2012 Page2NOYES Number of minor seizures over past 6 months: Number of major seizures: Average frequency of major.

 

NOTE: PLEASE READ CAREFULLY BEFORE SIGNING THE FRONT OF THEFORMVA will not disclose information collected on this form to any source other.

 

  IMPORTANT  - Physician please fax the completed form to 5C. LEFT VENTRICULAR EJECTION FRACTION LVEF , IF KNOWN: VA FORM MAY 2010, 21-0960A-1 8C. DATE SIGNED.

 

11C. TELEPHONE NUMBERS Include Area Code PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission.

 

DO NOT WRITE IN THIS SPACE VA DATE STAMP OMB Approved No. 2900-0740 Respondent Burden: 5 minutes REQUEST FOR SUBSTITUTION OF CLAIMANT UPON  DEATH OF CLAIMANT.

 

IMPORTANT: Report total gross income in Line 1, total expenses in Line 2, and total net income in Line 3. If the property or business is owned jointly,.

 

IF YOU HAVE ANY QUESTIONS ABOUT DISABILITY BENEFITS OR YOUR INSURANCE, PLEASE CALL OUR TOLL FREE NUMBER 1-800-669-8477 13. HOSPITALS WHERE YOU HAVE.

 

PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy.

 

12B. DATE OF MARRIAGE Month, day, year 13B. DATE OF MARRIAGE Month, day, year 13C. PLACE City/State or country 13D. TO WHOM MARRIED First.

 

 23. DID THE MISSING PERSON LIVE CONTINUOUSLY WITH SPOUSE FROM DATE OF MARRIAGE TO DATE OF DISAPPEARANCE  24. WAS THE MISSING PERSON OR HIS/HER SPOUSE ENAMORED.

 

Page 2 HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM Fully Developed Claim Process VA will provide a medical examination for you,.

 

PART II - VERIFICATION OF TERMINATION OF SCHOOL ATTENDANCE Continued To Be Completed By School 15. REMARKS I CERTIFYTHAT the foregoing statements are true and correct to the best of my knowledge.

 

You will receive all benefits due you for the year if your total annual earning do not exceed the limit shown in the letter attached to this form. If you earn.

 

I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I authorize any person or entity,.

 

DIRECT DEPOSIT INFORMATION Please provide account number 11. IF CHILD IS UNDER AGE 18 WHO HAS CUSTODY, IF OTHER THAN NATURAL PARENT Complete Items.

 

INSTRUCTION PARAGRAPHS 1. NUMBER OF UNMARRIED, DEPENDENT CHILDREN  VA recognizes the veteran s biological children, adopted children, and stepchildren as dependents. But these children.