21-0304

Application for Benefits for a Qualifying Veteran's Child Born with Disabilities

Agency
VA
Revision
May 2026
Fillable fields
84
Pages
4
Official source
VA form page
Checked
October 20, 2026
Fill 21-0304 online
Page 1 of form 21-0304

VA Form 21-0304: Benefits for a Qualifying Veteran's Child Born with Disabilities

VA Form 21-0304 is the U.S. Department of Veterans Affairs Application for Benefits for a Qualifying Veteran's Child Born with Disabilities. The form says to use it to determine eligibility for benefits for children with certain disabilities who are born of Vietnam veterans or certain Thailand or Korea service veterans.

The PDF is four pages. Page 1 is information and instructions that summarize the laws the application covers: 38 U.S.C. 1815 for children of women Vietnam veterans born with certain birth defects, and 38 U.S.C. 1805, 1821 and 1822 for spina bifida benefits tied to a parent's service in Vietnam, in or near the demilitarized zone in Korea, or in Thailand. Pages 2 to 4 hold the application in Sections I to VII, with the Privacy Act and Respondent Burden notices on page 4.

The form says to mail the completed application to the Evidence Intake Center in Janesville, Wisconsin. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 21-0304: Benefits for a Qualifying Veteran's Child Born with Disabilities, as printed by VA

What's on VA Form 21-0304

Section I: Child's identification

The child's name, Social Security number, which the form marks required, date and place of birth, whether a birth certificate was provided to VA, telephone number and mailing address.

Section II: Relationship with parents

Both natural parents' names, addresses, phone numbers, Vietnam, Thailand or Korea service and dates, Social Security numbers and VA claim numbers, then Item 10 for a custodian or guardian and Item 11 for a child age 18 or older declared incompetent.

Section III: Claim information

The disabilities claimed, the name and place first diagnosed and the date, the primary health care provider and address, and the names, places and dates of most recent treatment.

Section IV: Direct deposit

Account number with a checking or savings box, the financial institution's name and the routing or transit number, or Item 15 to certify there is no account with a financial institution or certified payment agent.

Sections V to VII: Certifications and signatures

An authorization for the hospital or physician in Items 12B, 13A and 14A to release information to VA, a declaration under penalty of perjury, the signature in Item 17A, witness lines and the alternate signer certification.

How to file VA Form 21-0304

  1. 1

    Read the information page first

    Page 1 says to read the information and instructions before completing the application, and the form points to the Privacy Act and Respondent Burden on page 4.

  2. 2

    Fill in the child and parent details

    Complete Sections I and II. If a birth certificate has not been provided to VA, or you are unsure, Item 4 says to attach a copy, and Item 10D asks the same for a decree of adoption or adoptive placement agreement.

  3. 3

    Describe the claim

    List the disabilities claimed in Section III with where and when they were first diagnosed and the most recent treatment.

  4. 4

    Add direct deposit details

    Enter the account in Section IV, or check Item 15 if there is no account. The form also points to va.gov/change-direct-deposit to enroll or change it online.

  5. 5

    Sign and date it

    Sign Item 17A, date Item 17B and print the name in Item 17C. A signature made with an X takes two witnesses in Section VI.

  6. 6

    Mail it

    Mail the completed application to the Evidence Intake Center in Janesville, Wisconsin.

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Where to send it and getting help

Mailing address

Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

Questions

The form points to Ask VA at https://ask.va.gov/ and the toll-free number 1-800-827-1000 (TTY: 711).

Direct deposit help

The form says the Department of the Treasury requires Federal benefit payments by electronic funds transfer. It lists https://www.benefits.va.gov/benefits/banking.asp for anyone without a bank account, and the Department of Treasury at 1-888-224-2950 for anyone who elects not to enroll.

Edition

The MAY 2026 edition supersedes VA Form 21-0304, MAR 2023. It carries OMB control number 2900-0572, which expires 05/31/2029, and a respondent burden of 10 minutes.

Related forms

Who uses VA Form 21-0304?

  • Adult children

    Section I identifies the child the claim is for, and Item 17A can be signed by an adult child.

  • Parents

    Item 17A can also be signed by a parent. Section II asks for information on both natural parents, including any service in Vietnam, Thailand or Korea.

  • Custodians and guardians

    Item 10 applies when the child is under age 18 and the custodian or guardian is other than a natural parent, such as an adoptive parent or guardian. A custodian or guardian can sign Item 17A.

  • Alternate signers

    Section VII is required only if Item 17A is blank. It lists a court-appointed representative, an attorney in fact or agent under a durable power of attorney, a person responsible for the claimant's care, or a manager or principal officer of an institution.

  • Witnesses

    Section VI has two witness lines, signed in ink, for when the adult child, parent or custodian or guardian signs Item 17A using an X.

The form names who signs and which parts apply to whom.

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Questions about Form 21-0304

What is VA Form 21-0304 used for?

The form says to use it to determine eligibility for benefits for children with certain disabilities who are born of Vietnam veterans or certain Thailand or Korea service veterans.

Which laws does the form describe?

Page 1 describes 38 U.S.C. 1815 for children of women Vietnam veterans born with certain birth defects, and 38 U.S.C. 1805, 1821 and 1822 for spina bifida benefits linked to service in Vietnam, Korea or Thailand, each with its own service dates.

Can benefits be paid under both laws?

The form says the law does not allow payment of both benefits at the same time, and if entitlement exists under both laws, benefits will be paid under 38 U.S.C. 1815.

What other benefits does the information page mention?

It mentions health care covering the defects or any disability associated with them, vocational training through VA's Veteran Readiness and Employment Service, and levels of monetary allowance based on the child's level of disability.

Does the application need a birth certificate?

Item 4 asks whether a copy of the child's birth certificate has been provided to VA. If not, or if unsure, it says to attach a copy with the form.

Who can sign VA Form 21-0304?

Item 17A is for the adult child, a parent or a custodian or guardian. Section VII lets an alternate signer sign when Item 17A is blank.

Where do I mail VA Form 21-0304?

The form lists Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.