PDF FILES: ATTESTATIONS AND EXHIBITS
The Fund is providing the PDF files below to assist you in filing your claim. These files can be downloaded and printed for your convenience. Except where noted, these are provided as fillable PDF files that allow you to type the information into the forms rather than completing them by hand. Once the information is entered, you can print, sign, and date the form and mail it to the Fund. You may also save a copy of the file on your computer.
Please remember that regardless of whether you are submitting your claim online or using a hard copy claim form, you must mail a complete, original Exhibit A - "Authorization for Release of Medical Records" with original signatures to the VCF. If you are filing your claim online, you are encouraged to upload all other Attestations, Certifications, Exhibits and supporting documents to your online claim and are not required to mail the documents to the VCF.
If you decide to use the fillable versions of the Attestations and Exhibits, please note the following:
- The Eligibility Form Attestations files are available in two formats: as a single file with the complete set of Attestations and as separate files with one Attestation per file. If you are completing the Attestations as part of your initial claim submission to the VCF, please use the single file with the complete set of Attestations. If the VCF has contacted you to request that you submit a specific Attestation, please use the individual file for the particular Attestation.
- Enter ALL information on the form using ONLY CAPITAL LETTERS.
- If you enter information into one of these files and save it to your computer, please remember that it contains personal information. You may not want to save the file on a public or shared computer where others have access.
If you are submitting your claim online:
- Please complete Part IV – Attestations via the appropriate section of the online form and print the file using the “Print” button at the bottom of the page. Please note that the online system includes the complete set of Eligibility Form Attestations and does not include the ability to complete individual Attestations. If you need to submit only a subset of the Part IV Attestations, please use the individual files below.
- You can also access the Exhibits files through the online claim form.
If you need assistance completing your claim form, please visit www.vcf.gov or call our toll-free Helpline at 1-855-885-1555 (or 1-855-885-1558 for the hearing impaired). If you are calling from outside the United States, please call 1-202-353-0356.
*These forms are not available as fillable PDFs but can be downloaded, printed, and then completed.