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Veterans Disability Authorization 12132017.doc Cortland County Office of Personnel/Civil Service 60 Central Ave Cortland, NY 13045 1. TO BE COMPLETED BY VETERAN Type or print in ink, and send two copies of this form to the Department of Veterans Affairs where your disability claim is on file. To Chief, Veterans Benefits and Services Division , N.Y. I hereby authorize you to furnish the above Civil Service Agency with the data requested in Section 2 below pertaining to my disability status. You are released from all liability in complying with this request. It is understood that all information furnished will be treated as confidential. Print Full Name V.A. Claim Number Service Number Address Number and Title of Examination(s) for which credit is claimed Social Security Number Veteran’s Signature Date: 2. TO BE COMPLETED BY VETERANS BENEFITS ADMINISTRATOR Please return original to the Civil Service Agency at address indicated at top of form. Date Claim Number Regional V.A. Office a. Does the above-named veteran now have a war-incurred disability? If Yes, please enter date disability was sustained. Date: Yes No b. Date of VA Disability Determination: c. State percentage of such disability now in existence. % d. Date of last medical examination by the V.A. Medical Officer in connection with such disability. (If less than one year ago, do not answer e and Date: e. Does the V.A. state affirmatively that a permanent stabilized condition of disability exists to an extent of 10% or more, even though the veteran has not been examined by V.A. Medical Officer within one year? Yes No f. Date of next scheduled medical examination by the V.A. Date: g. Remarks Signature of Adjudication Officer: PERSONAL PRIVACY PROTECTION LAW NOTIFICATION The information which you are providing on this application is being requested in accordance with section 85 of the Civil Service Law for the principal purpose of establishing your status as a disabled veteran and processing your application for additional credit. This information will be used in accordance with section 96(1) of the Personal Privacy Protection Law, particularly subdivisions and Failure to provide this information may result in the disapproval of your application. The information will be maintained by the Municipal Civil Service Commission or Municipal Personnel Officer administering the examination. For further information relating to the Personal Privacy Protection Law, call (518) 457-9375. If you have a question regarding this information, you should contact the Municipal Civil Service Commission/Personnel Officer administering this examination. DISABILITY RECORD AUTHORIZATION (Updated 12/26/13)