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Patterns form label masterlist

Below is a list of standardized form labels that appear on forms. This list is a continued work in progress as each form is unique and has specific labels and questions. As we migrate more forms online, we’ll continue to add plain-language labels to this list.

Form section Plain-language label or question Followup label or question Form notes  
Applicant information Your first name      
  Your middle name      
  Your last name      
  Mother’s maiden name   HCA only  
  Your date of birth      
  Your place of birth      
  Social Security number      
  VA file number      
  Which categories best describe you? • Spanish • Hispanic • Latino • American Indian or Alaskan Native • Black or African American • Native Hawaiian or other Pacific Islander • Asian • White HCA  
  What is your race, ethnicity, or origin? (Please check all that apply.) • American Indian or Alaskan Native • Asian • Black or African American • Hispanic, Latino, or Spanish origin • Native Hawaiian or other Pacific Islander • White • Another race or ethnicity • Prefer not to answer Coronavirus research volunteer list  
  Which of these best describe you? • Veteran • Active-duty service member • Member of the National Guard or Reserve • VA employee • Family member or caregiver of a Veteran or service member • Enrolled in VA health care or CHAMPVA • None of the above Coronavirus research volunteer list  
  What is your gender? (Please check all that apply.) • Man • Woman • Transgender man • Transgender woman • Non-binary • Prefer to self-describe • Prefer not to answer    
Contact information Address Country, Street address, Line 2, Line 3, City, State, Postal code    
  Home address   These are the labels used in profile  
  Mailing address   These are the labels used in profile  
  State or territory      
  Email address      
  Confirm email address   Appears as Re-enter email address on some forms  
  Primary email address   Pension only  
  Secondary email address   Pension only  
  Home phone number      
  Mobile phone number      
  How should we get in touch with you?      
  How should we contact you if we have questions about your application? Mail, Email, Home phone, Mobile phone    
  To update your contact information for all of your VA accounts, please [go to your profile page].      
  To update your address for all of your VA accounts, go to your profile page. [View the address that’s on file in your profile].      
  I would like to receive text messages from VA about my [benefit type] benefits.      
Military address I live on a U.S. military base outside of the country. [Additional info component] U.S. military bases are considered a domestic address and a part of the United States.    
Marriage information What’s your marital status?      
  Spouse’s first name      
  Spouse’s middle name      
  Spouse’s last name      
  Spouse’s suffix      
  Spouse’s Social Security number      
  Where did you get married? City, State    
  When did you get married?      
  When did your marriage end?      
  Why did your marriage end?      
  Where did your marriage end? City, State    
  Type of marriage Ceremonial, Common-law, Proxy, Tribal, Other    
  How many times have you been married?      
Sponsor information Sponsor’s first name      
  Sponsor’s middle name      
  Sponsor’s last name      
  Sponsor’s suffix      
  Sponsor’s Social Security number      
  Sponsor’s VA file number      
  Sponsor’s date of death or date listed MIA or POW      
  Where did your sponsor die? City, State    
  Is your sponsor on active duty?      
  What’s your relationship to the service member whose benefit is being transferred to you?      
Caregiver information Primary Family Caregiver’s first name label is same for Secondary Family Caregiver Caregiver form  
  Primary Family Caregiver’s middle name      
  Primary Family Caregiver’s last name      
  Primary Family Caregiver’s Social Security or tax identification number      
  Primary Family Caregiver’s date of birth      
  Primary Family Caregiver’s sex      
  Primary Family Caregiver’s current street address      
  Primary Family Caregiver’s primary phone number (including area code)      
  Primary Family Caregiver’s alternate phone number (including area code)      
  What’s the Primary Family Caregiver’s relationship to the Veteran?      
  Does the Primary Family Caregiver applicant have health care coverage, such as Medicaid, Medicare, CHAMPVA, Tricare, or private insurance?      
Service history Last branch of service   Health care app  
  Branch of service      
  Sponsor’s branch of service      
  Service start date      
  Service end date      
  Character of service   This could also be Character of discharge  
  Service history      
  Type of service Active duty, drilling reservist, National Guard, IRR    
  Are you currently on active duty?      
  Did you serve under another name?      
  Place of last or anticipated separation from service City, State, or Foreign country    
  Are you currently on federal active duty in the National Guard?      
  Are you currently activated on federal orders?      
  Activation start date      
  Expected separation date      
  Obligation start date      
  Obligation end date      
  Most recent entry date      
  Have you ever been a POW?      
  Start of confinement?      
  End of confinement?      
  Have you received any type of severance or separation pay?      
  Do you have any periods of service that began before 1978?      
  Unit name      
  Military Service number      
Dependent information Do you have any dependents to report?      
  Do you have any dependent children?      
  What’s your dependent’s relationship to you?      
  Dependent’s first name      
  Dependent’s middle name      
  Dependent’s last name      
  Dependent’s suffix      
  Dependent’s Social Security number      
  Dependent’s date of birth      
  When did they become your dependent?      
  Does your child or dependent live with you?      
  Was your dependent permanently and totally disabled before the age of 18?      
  If your dependent is between 18 and 23 years old, did they attend school during the last calendar year?      
  Expenses your dependent paid for college, vocational rehabilitation, or training      
  Has your child ever been married?      
  Did your dependent live with you last year?      
  Do you have the same address as your spouse?      
  Do you have the same address as your dependent?      
Income information Annual income      
  What’s your gross annual income from employment?      
  What’s your net income from your farm, ranch, property, or business (if applicable)      
  Do you have any other income?      
  What’s your spouse’s gross annual income from employment?      
  What’s your spouse’s net income from your farm, ranch, property, or business? (if applicable)      
  Does your spouse have any other income?      
  Amount you or your spouse paid in non-reimbursable medical expenses this past year      
  Amount you paid in funeral or burial expenses for a deceased spouse or child this past year      
  Amount you paid for anything related to your own education (college or vocational) this past year. You don’t need to list your dependents’ educational expenses.      
  Account type      
  Bank account number      
  Bank routing number      
  Bank accounts, investments, and property      
  Social Security or other pensions (gross income)      
  Do you have any medical, legal, or other unreimbursed expenses?      
  Amount paid      
  Paid to      
  Date paid      
  Are you receiving military retired pay?      
  Expected income Any income you didn’t already report in this form that you expect to receive in the next 12 months    
  Which type of VA compensation do you currently receive?      
Health care information Are you eligible for Medicaid?      
  Are you enrolled in Medicare Part A (hospital insurance)?      
  Are you covered by health insurance? (Including coverage through a spouse or another person)      
  Provider name      
  Policyholder’s name      
  Policy number (either this or the group code is required)      
  Group code (either this or policy number is required)      
  I’m enrolling to get minimum essential coverage under the Affordable Care Act      
  Please choose your preferred VA medical facility      
  Do you want VA to contact you to schedule your first appointment?      
Education information Which benefit have you used or are currently using? • Post-9/11 GI Bill (Chapter 33) • Fry Scholarship (Chapter 33) • Montgomery GI Bill (MGIB-AD, Chapter 30) • Montgomery GI Bill Selected Reserve (MGIB-SR, Chapter 1606) • Transfer of Entitlement Program (TOE) • Post-Vietnam Era Veterans’ Educational Assistance Program (VEAP, Chapter 32)    
  Are you applying for the Edith Nourse Rogers STEM Scholarship?      
  Are you enrolled in a STEM undergraduate degree program?      
  What’s the name of your STEM degree?      
  Name of the school where you’re planning on using the Rogers STEM Scholarship?      
  Name of school, university, or training facility you’re attending      
  Type of education or training      
  Your school student ID number      
  Your school email address (This email address usually ends with .edu.)      
  Education or career goal (For example, “I want to get a bachelor’s degree in criminal justice” or “I want to get an HVAC technician certificate” or “I want to become a police officer.”)    
  Are you getting, or do you expect to get any money (including, but not limited to, federal tuition assistance) from the Armed Forces or public health services for any part of your coursework or training?      
  Are you getting benefits from the U.S. government as a civilian employee at the same time you’re requesting VA benefits?      
  When did you stop taking classes or participating in the training program? (Future dates are ok.)      
  Why did you stop taking classes or participating in the training program? (For example, “I graduated” or “I moved” or “The program wasn’t right for me.”)      
  When did you earn your high school diploma or equivalency certificate?      
  Hours completed      
  Type of hours      
  Degree, diploma, or certificate received      
  What did you study?      
  If you have any FAA flight certificates, please list them here      
  Have you ever held a license of journeyman rating (for example, as a contractor or plumber) to practice a profession?      
  Main job      
  Number of months worked      
  Is student’s tuition or education allowance being paid by the Survivors’ and Dependents’ Educational Assistance (DEA), the Federal Compensation Act, or any U.S. government agency or program?      
Burial information What expenses did you incur for the Veteran’s burial?      
  Type of burial allowance requested      
  Date of death      
  Date of burial (includes cremation or interment)      
  Is there anyone currently buried in a VA national cemetery under your eligibility?      
Disability information Please tell us what type of disability claim you’re filing      
  Did you serve in a combat zone after Sept. 11, 2001?      
  Do you have any new conditions you want to add to your claim?      
  What caused this service-connected disability?      
  Do you need help buying or modifying your home?      
  Do you need help buying or modifying your car?      
  Are you confined to your home or need help with everyday activities?      
  Does your disability prevent you from holding down a job that you could otherwise do? (This doesn’t include being retired.)      
  What is your work situation?      
  Please tell us where VA treated you for your disability      
  Name of VA medical facility      
  After we review your disability claim and supporting evidence, we may ask you to have a claim exam (also known as a C&P exam) if we need more information to decide your claim.      
  We’ll use the results of this exam, in addition to your supporting evidence, to rate your disability.      
  Is there any evidence you’d like us to review as part of your claim?      
  What type of evidence do you want us to review as part of your claim?      
  Are you terminally ill?      
Pension information Are you currently on federal active duty in the National Guard?      
  Have you had a job (including self-employment) from 1 year before you became disabled to now?      
  Employer name      
  Employer address      
  Job title      
  What disabilities prevent you from working?      
  Date your disability began      
  Have you been treated at a VA medical center for the above disability?      
  How many days were lost due to your disability?      
Housing information Are you currently homeless?   Disability compensation form  
  Please describe your current living situation I’m living in a homeless shelter • I’m living somewhere other than a shelter (For example, I’m living in a car or a tent.) • I’m living with another person • I need to quickly leave where I currently live • Other (Please describe)    
  Please describe your current living situation • I’m losing my housing in 30 days • I’m leaving a publicly funded homeless shelter soon • Other (Please describe)    
  Are you currently at risk of becoming homeless?      
  Please provide the name and number of a person we can call if we need to get in touch with you      
Review and submit content Please review the information below to ensure that it’s correct before you submit your application. This is especially important if you worked on your application over several days.      
  Do you want to apply under the Fully Developed Claim program?      
Last updated: 1/26/2021