Sections I and II: identification
Items 1 to 12 ask for the Veteran's or beneficiary's details and the claimant's name, Social Security number, relationship to the Veteran, date of birth, mailing address, optional telephone and optional email.
21-2680
Examination for Housebound Status or Permanent Need for Regular Aid and Attendance
- Agency
- VA
- Revision
- June 2026
- Fillable fields
- 112
- Pages
- 4
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-2680: Examination for Housebound Status or Need for Aid and Attendance
VA Form 21-2680 is the U.S. Department of Veterans Affairs Examination for Housebound Status or Permanent Need for Regular Aid and Attendance. VA's form page says to use it to apply for Aid and Attendance benefits that will be added to your monthly compensation or pension benefits. The form's instructions say it is used to determine eligibility for aid and attendance or housebound benefits.
The PDF has four pages. Sections I to V hold the Veteran's and claimant's details, the benefit chosen, hospital information and the claimant's signature. The form says the remainder, from Section VI on, is filled out by the examiner, who it says is a Medical Doctor (MD) or Doctor of Osteopathic (DO) medicine, physician assistant or advanced practice registered nurse.
VA's page says you can also apply online. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21-2680
Section III: claim information
Item 13 asks the claimant to choose one benefit: Special Monthly Compensation (SMC), which the form says is paid in addition to monthly compensation or DIC, or Special Monthly Pension (SMP), an increased monthly amount for those eligible for Veterans Pension or Survivors benefits.
Sections IV and V: hospital and signature
Items 14A to 14D ask about a current hospital stay. Section V is the claimant's certification, with the signature in Item 15A and the date in Item 15B.
Section VI: examination findings
Items 16 to 25 record the exam date, diagnoses with their most significant symptoms, disabilities considered permanent and totally disabling, age, weight, height, nutrition, gait, blood pressure, pulse and respiratory rate.
Section VI: daily activities
Items 26 to 37 cover hours in bed, help needed with activities such as bathing, dressing and medication management, vision, nursing home care, capacity to manage benefit payments, limb and spine restrictions, leaving the home and walking aids.
Sections VII and VIII: examiner
The examiner's printed name, title, required signature and date, National Provider Identifier, and the medical facility's name, address and telephone.
How to file VA Form 21-2680
- 1
Read page 4 first
The instructions say to read the Privacy Act and Respondent Burden on page 4 before completing the form.
- 2
Fill in Sections I and II
Enter the Veteran's and claimant's details. If completing by hand, the form asks for neat, legible printing in ink and fully filled check boxes.
- 3
Choose one benefit
In Section III, check either Special Monthly Compensation or Special Monthly Pension.
- 4
Answer the hospital question and sign
If the claimant is hospitalized, complete Items 14B to 14D; if not, the form says to skip to Section V. Sign Item 15A and date Item 15B.
- 5
Have the examiner complete the rest
The examiner fills in Sections VI to VIII. The form's note asks the examiner to show how well the claimant ambulates, where they go and what they are able to do during a typical day.
- 6
Send it or apply online
The PDF does not print a mailing address. VA's form page says you can apply online instead of filling out and sending the paper form.
Why fill Form 21-2680 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Applying and getting help
Online
VA's form page says you can apply online instead of filling out and sending the paper form.
Questions
The form points to Ask VA at https://www.va.gov/contact-us/ask-va/introduction and the toll-free number 1-800-698-2411 (TTY: 711). VA forms are available at www.va.gov/vaforms.
Nursing home information
VA's page lists VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance, as a related form.
Edition
The JUN 2026 edition supersedes the FEB 2023 edition. It carries OMB Control No. 2900-0721, which expires 06/30/2029, and a respondent burden of 30 minutes.
Related forms
21-0779
Request for Nursing Home Information in Connection with Claim for Aid and Attendance
51 fields, 2 pages
21-526EZ
Application for Disability Compensation and Related Compensation Benefits
345 fields, 15 pages
21P-527EZ
Application for Veterans Pension
477 fields, 17 pages
21P-534EZ
Application for D.I.C., Survivors Pension, and/or Accrued Benefits
626 fields, 20 pages
21P-8416
Medical Expense Report
517 fields, 10 pages
21-4138
Statement in Support of Claim (VA Form 21-4138)
33 fields, 2 pages
Who uses VA Form 21-2680?
The form is split between the claimant, who fills in Sections I to V, and an examiner, who fills in the rest.
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Questions about Form 21-2680
What is VA Form 21-2680 used for?
VA's form page says to use it to apply for Aid and Attendance benefits that will be added to your monthly compensation or pension benefits. The form says it is used to determine eligibility for aid and attendance or housebound benefits.
Who fills out the examination part?
The form says the remainder of the form, from Section VI on, is filled out by an examiner who is a Medical Doctor (MD) or Doctor of Osteopathic (DO) medicine, physician assistant or advanced practice registered nurse.
What is the difference between SMC and SMP on the form?
The form describes Special Monthly Compensation as paid in addition to monthly compensation or Dependency Indemnity Compensation (DIC), and Special Monthly Pension as an increased monthly amount paid to a veteran or survivor who is eligible for Veterans Pension or Survivors benefits. Item 13 asks the claimant to choose one.
What if the claimant is in the hospital?
Section IV asks whether the claimant is hospitalized. If yes, the form asks for the date admitted and the hospital's name and address in Items 14B to 14D.
Can I apply online?
Yes. VA's form page says you can apply online instead of filling out and sending the paper form.
Which form does a nursing home official use?
VA's page lists VA Form 21-0779 for a nursing home official to verify that a Veteran or someone connected to a Veteran is a patient in a qualifying extended care facility.