Questionnaire Text

Questionnaire form view entire document: text image

b) What is this person's service-connected disability rating?

[ ] 0 percent
[ ] 10 or 20 percent
[ ] 30 or 40 percent
[ ] 50 or 60 percent
[ ] 70 percent or higher

Questionnaire instructions view entire document: text image

28a. Mark the "Yes" box if the person has a Department of Veterans Affairs (VA) service-connected disability rating.