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FOR WHAT BENEF_lT ARE You APPLY|NG? 4 §- coMPENSAT»loN § PENsloN § BOTH co_MPéNSATlON AND PENSloN 2 HAVE YOU PREV|OUSLY APPLIED FOR ANV VA BENEF|T(S) ? (( /mkapplicab/e hu.x) § PENSloN § coMPENSATloN § oTHER(Specify) 3. F|R’STl M|DDLE, LAST NAME OF VETERAN w .n._ 4A. VETERAN'S SOC|AL SECUR!TY NO. 4B. VA F|LE NUMBER ([/`a/)p/i¢~ab/e) 4C. SPOUSE'S SOC\AL SECUR|TY NO.` 4D. lF YOU SERVE_D U[\JD§R ANOTHER NAME, G|VE NAME AND PER|OD DUR|NG WHlCH YOU.»SERVED A`ND SERV|CE NO. 5. MA|L|NG ADDRESS (N11111/1e1' and .\‘Ireel ar rural rr)u/¢.'. c/'Iy ur l’.()., Slale and le’ ('.'r)de) 6 TELEPHONE NUMBER(S) (lnc/udu Area(_. ade) 7-.‘E-MA\_LADDRESS_(l/`£lpp/ic‘ab/€) A. DAYT|ME B EVEN|NG C CELL aA. DATE OF BlRTH 11140,111,, day year/ eB. PLACE oF BlRTH .' 9. sE>< 4 1 , - . 1 `. § MALE § FEMALE 10A' HAVE YOU EVER F|LED A CLA!M FOR COMPENSAT|ON FROM 1OB. WHEN WAS THE CLA|M F|LED? 1OC. EOR WHAT DlSAB|LlTY ARE YOU THE oFFlcE oF WORKERS' coMPENsAT10N PROGRAMS? W”~ d”y- .v'-/ ' _RECE'V'NG BENEF'TS? (l"r)rmer/y /lw l/..S`. Bureau Qf`l;'n_1[)l0yee.\' Compenmlion) _ . af § YES {:] NO' a (If "Yes. " cbn1}1/ete ltems ]0B & /()C) 11 PLEASE PROV‘DE NATURE OF SICKNESS. D|SEASE OR |NJUR|ES FOR WH|CH TH|S CLA|M lS MADE; DATE i:ACH BEGAN; AND PLACE OF TREATN|ENT A. LIST DlSABlLlTY(lES) ` B. DATE BEGAN C. PLACE OF TREATMENT * 12A ARE You NOW oR HAVE You REcE\vED -` 123 DATES oF TREATMENT/cARE 120. NAME.AND ADDRESS 0F vA MED|CAL FAC|L|TY TREATMENT OR DOM|C|LIARY CARE AT A VA . 1 ' (]fy()u need more .\'pace use llem 45, "l\’emark.\") MEDacAL FAclL\TY? M°""' Day' _ Ye~a' ‘ § YEs` § No (1f"Yes,"comp/e1e lzem; 1213 &12C) 13A'. HAVE YOU EVER BEEN A PR|SONE_ER OF WAR? - 135. NAME QF COUNTRY ' ' 13C, DATE_S OF CONF|NEMENT 1 w - "" ` FRoM . _ 10 [:] YES m NO (l/ Ye.\' comp/ere /Iem.\' I.JB ami l3() . 4 ` n _ 14 ~ 0 14 ARE YOU CLA\M|NG A D|SAB|L|TY RELATED TO AGENT ORANGE OR ' _` _ 15. ARE YOU CLA|MlNG A DlSABlLlT_Y RELATED TO ASBESTOS OTHER HERB|C|DE EXPOSURE'? (l_/ "Ye.\,"/1\(di.\11/)iliL\1(ic.s) helrm) ' l EXPOSURE? (I_/ "Ye.\'. "11\1 disabllily(ies) be/ou) §YES§NO ` "§YES§NO 16 ARE YOU CLA|M|NG A DiSAB|L|TY RELATED TO MUSTARD GAS EXFOSURE? 17. ARE YOU CLA|M|NG A D|SAB|L|TY RELATED TO |ON|Z|NG RAD|AT|ON (l_/ "Yc.\ "liv/ dl.\ab/I/`/y(iu\) hclm¢) EXPOSURE'? (l/"YL'A',"/i.vldi.vabiliL\/(ie.§) hel¢)w) §YES§NO ._ _ §YE_s'§ No __ ,__.,., w . 18. ARE YOU CLA|M\NG A D|SAB|L\TY RELATED TO AN ENVIRONMENTAL HAZARD EXPOSURE DUR|NG THE GULF WAR? (If'"Yc.\', " /1'.\'1 di.\'abili/y(ies) bela\v) § YEs § No ‘ YOU MUST SlGN AND PR|NT YOUR NAME AND DATE TH|S FORM lN lTEMS 42A THRU 420 ON PAGE 10. VA FORM SUPERSEDES VA FORM 21-526, JUN 2014. Nov 2014 21'526 WH|CH W|LL NOT BE USED. PAGE 5 5 1 C,¢%@Q,L”: 1 L\` \<;;<<‘,11@1 1,`¢_ "T°Av/?`;w;§? y 191 v_;?\;,1§;__;@;:__.s:‘r’_“__11-1,~1’¢~ 1~§5~1"~1)=,@._@,1» 512*1'~1@`§ __,g"*~w'§'~ » - D\A".§»%»M\@~¢»¢ :’”1-_%_“1':11 ‘..-: C_m.u' witt C_@,§M§m;<'_ 131 PP¢§;\$._ SUM;'@`NE"Q Q;UM_J> §§M';L_l,;~~cg 1 P..®. HU§ mgng C_M;HL SM+,*W` 1311 m ey.<.v1_§@@1,~1 -AUSMN ‘°1‘;<, "'=1.1:"111... '{ SCF@q,@HH O Y.D£a. @:&¢1`§"4`~11\1 §‘U:.'LEMUMQHDM o?NQchQd ‘DAJ @@1’§2»1<@, H\\M KM'M-m.§ d.@w@.m @/W \1\1511» w Cu!u. <~_11, LQ»H~- U?-» ' SCFD\ Q@: »1@§ »©'B., UN 1@ TC'§S+'@"\L.@ EQ@MMJ» ama @..@an, D@m.cm c.»>.»\+” §S§@\»BQWG@ S¢UQT€W D@?‘MT%~'M/M”* @FH§.J@'EB{%._<»@£,\M`@J~_ ?ZJM» \LS` F\'Qm\¥ g AKW’N QC.\\`e?.\M E>Ud@.&s ASP/»r.\[© b 1~\ 12m~1 am 1241 1%11» Cm~MU-.W 111 m 51 1 1-;911,.~1 €?,ew@,d l"'\®\ BQUA~ 3d1 ;S+' lms F@WJ 11 12,1 11-..:1+1,»» \1,@ Zzz;m\. ~111$3 C/~\ 56 m/@M 1139 m" YOU MUST S|GN AND PRINT YOUR NAME AND DATE TH|S FORM |N-lTEMS_ 42A THRU 420 ON PAGE 10. PAGE 7 State Counsel for Offenders Texas Depart_ment of Criminal Justice P O. Box 4005 - Huntsvi||e,TX 77342-4005 ' (936) 437-5203 May12,2_015 lJoseph Ceaser TDCJ ID#. 19_4.4()45 Estelle Unit (E2/032) Dear Mr. Ceaser: We recently received your letter asking for assistance with sex registration; The ]'" able of Contents in Chapter 8 in Volurne 1 of the State Counsel for Offenders Legal Handbook contains general information Since sex registration is a paiole (and 11 ec World legal issue), you must obtain the assistance ot an outside attorney that practices in this area of law You can find addresses 1n the Texas Legal Directory (Blue Books). Both the Legal Handbook and the Blue Books are in the unit law library. The law librarian can assist you in finding the information referenced herein. L&\M O§u\im.n_, ref Dt, JLo/jv . ' ` "11:4:1 ?.r_ag`f' Ltp+z` 5~1~ HLASMM Tle `12`.1@;§' _ cc:File ' .¢ . ._ _ … 1{- fl ../ TC_)( 013 A§SOC,`D{~!`D:\\ AS\`!\$F Se,v\mn.i__ P»_;_sozl+ ' . T‘C.XA$ C.`\\ii\_ R`\§\N\" Ploje§+ ’L.'?_.Qz._ E. 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RATlNG, ORGANlZAT|ON DATE PLACE DATE ' PLACE NOTE: Enter complete information for each period of Reserves and National Guard service Attach any separation papers you have.- 20A. ENTERED 1Nr0 sEvacE _ 205. sEercE zoc_ sEPARArED Fr=_zorvr sEvaeE S::';b:ET€Y'_?F' zoE. GRADE, RANK on ` , NuMBER ` _ (_"""“ RAT|NG, oRGAleATlON DATE PLACE ` DATE PLACE N“"“"“' ""”"/} _/’ "_ "_" . 21 rF DrsAeiLiTY occuRRED DuRiNG AcrivE oR 1NAcT1vE 22A ARE You Novv A MEMBER oF THE RESERVES 223 RESERVE STATUS ourv FoR rRAerNG GrvE BRANCH oF sERvicE AND DATE on NATroNAL GUARD? rF so erer _THE BRANCH l:| ACT,VE l:| RESERVE oF occuRRENcE 01= sERvicE _ ostreAnoN t [:| _YES |:] NO BRANCH [| inAcrl\/_E 22C. NAME, ADDRESS AND PHONE NO_. OF RESERVE OR NAT|QNAL GUARD UN|T (I_/`au'dilir)na/ space i.\' needed, u.vu llem`,45 "Remark.s"') lMPORTANT » Unless you check the box in item 25 below, you are telling us that you are choosing to receive VA compensation instead of military retired pay, if it is determined you are entitled to both benei'rts. ll you are awarded military retired pay prior to eompensation, we will reduce yo'u`r retired pay by the amount of any compensation'that you are awarded VA will,notify the Military Retired Pay Center of all benefit changes lf you receive both military retired pay and VA compensation, some ot" the amount you receive may be recouped by VA` or, in the case of Voluntary Separation l`ricentive (VSI), by the Depanment of_Defense. 23A. ARE YOU RECE|V|NG MiLlTARY 23B. W|LL YOU RECEi\/E MILITARY RET|RED PAY lN THE 230- BRANCH OF 230. MONTHLY RET|RED PAY? (lf "Yes, "complele FUTURE? ([f ")'es, "éxp/ain, i.e, Fu_ture Reserve/National Guard - SERV|CE AMOQNT ltems 23C & 23D) Retiremenl, }’ending MEB/PEB) ' g YEs l:l No ij YEs_ [:l No $ 241 RET|RED STATUS 25. NO, l DO NOT WANT VA COMPENSAT|ON lN LlEU OF M|L|TARY RET|RED PAY' l:l RETrRED m TEMPORARY DlsABlLiTY [:] DlsABLED (Check box.'ifapplicable) l:] RETIRED LlST RET|RED LlST '26 HAVE YOU EVER APPL|ED FOR OR RECE|VED DlSABlL|TY SEVERANCE/SEPARAT|ON PAY OR AN_Y OTHE_R LUMF SUM PAY|V|ENT FROM THE ARMED FORCES? (l_/ "YL'\. "ll\'l type alm)rurl dale il \111.\' rcc¢.'i\ezl. mull/w branch uf .\cri ice hc/r)\r') |:| YEs m No- 27A MAR|TAL STATUS (l_/ married c()/np/ele ]Ienl.\' 2 7/1‘ lhru 29/)) . 27a sPouSES'S BlRTHDATE (M11.. 11¢1,11._111.) E] MARR|ED [:] WlDoWED l:| DlvO_RcED ' |:] NEVER MARRiED(//111»11)11111111111/, 1111/1111/1€11131)) " '- 27€1. NUMBER OF T|_MES 27D~ NUMBER OF T"V|ES YOUR 27E. IS,¥OUR SPOUSE ALSO A VETERAN? '27F. SPOUSE'S VA F|LE NUMBER (Ifany) YOU HAVE BEEN PRESENT SPOUSE H.AS ' - . ` - MARRlED (l`u include ..BEEN MARR!ED (7`0 l:' YES l: NO (lf"Yes, "comp/ete '. ' CW"¢"" ”'””"”XL’) include current marriage) l - ' '[lem 2 7}") . _ ~ " C- 27G. DO YOU LlVE TOGETHER? 27H. REASON FOR SEPARATION (l"r)r example`, __ - 27|y PRESENT ADDRE$S OF SpOUSE ' niarila/ proh/cm.\'.jr)b ruqr/il'uniul1l.r, hea/Ih, elc`,) ' ,)_. |:’ YES |:} NO (lf "No, "comp/ele llems_27H thru 27./) w 27.1. AMOUNT ¥OU CONTR\BUTE TO YOUR 271< HOW WERE YOU MARR;ED') SPOUSE'$ MONTHLY SuPPORT |:| CLERGYMAN OR AUTHOR,ZED l:] TR|BAL I:| OTHER (EXp/am) PuBch oFFicrAl_ [:| coMMON-LAW |:] PROXY YOU MUST S|GN AND PR|NT YOUR NAME AND DATE TH|S FORM |N |TEMS.42A THRU 42C ON‘PAGE 10. PAGE 6 l "'. 1 ~ . . omitL nw MC@~WT wmme las 1__11;11 anton \1\1¢11.‘11 ms JJ_A.. m__MD._ _\_}o-DAQL D_l?_/pu.a_ l€_/Y\_ M_a_..u»._. 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