APPLICATION FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

PRIVACY ACT STATEMENT

AUTHORITY:  10 U.S.C. 1413a, E.O. 9397, November 1943 (SSN), PDUSD(P&R) Memorandum (May 21, 2003), Subject: Combat-Related Special Compensation (CRSC).

PRINCIPAL PURPOSE(S):  Used by members to apply for Combat-Related Special Compensation (CRSC).  Application is reviewed to determine eligibility.  Information provided by the member is used to identify the individual and the member's service record, determine eligibility for Combat-Related Special Compensation under 10 U.S.C. 1413a, and determine the amount and effective date of payment.

ROUTINE USE(S):  Information may be provided to the Department of Veterans Affairs (VA) for these purposes; to the Internal Revenue Service with respect to matters relating to an individual's tax status, and to the Department of Justice or state or local governments when a question of conflicting interest is raised concerning a member's declaration and application for compensation.

DISCLOSURE:  Voluntary; however, failure to provide any required information may result in member not being considered eligible for Combat-Related Special Compensation.

COMPLETE THE FORM CAREFULLY AND ACCURATELY.

GENERAL INSTRUCTIONS.

     Complete and submit this form to apply for Combat-Related Special Compensation (CRSC).  Print, type, or use a computer and provide the best information available.  If you don't know the answer, enter "Don't Know" or "DK" - do not leave any item blank.

     If you need assistance to complete this form, contact your Uniformed Service Retirement Representative or go to the web site https://www.dmdc.osd.mil/crsc/ for additional information and assistance.

     Sign and date your application.  Enclose with your application a clean legible copy of any supporting documents.  DO NOT SEND ANY ORIGINAL DOCUMENTS, AS THEY WILL NOT BE RETURNED.

     Send your application package to the address listed below for the Uniformed Service from which you retired.

ARMY:                                                                                                       COAST GUARD:

U.S. Total Army Personnel Command                                              Commander (adm-1-CRSC)                                     U.S. Army Physical Disability Agency (CRSC)                                          U.S. Coast Guard                                                        c/o The Adjutant General Directorate                                                       Personnel Command                                               2461 Eisenhower Avenue                                                                              4200 Wilson Boulevard                                   Alexandria, VA 22331-0470                                                                                       Arlington, VA 22203-1804

NAVY AND MARINE CORPS:                                                                NOAA CORPS:

Department of the Navy                                                                        Director, Commissioned Personnel Center                                Naval Council of Personnel Boards                                                   SSMC3/Room 12100                                                              Combat-Related Special Compensation Branch                                           1315 East West Highway                                                              720 Kennon Street S.E., Suite 309                                                             Silver Spring, MD 20910                                                  Washington Navy Yard, DC 20374-5023

AIR FORCE:                                                                                              PUBLIC HEALTH SERVICE:

United States Air Force                                                                              United States Public Health Service                                     Disability Division (CRSC)                                                                                          Division of Commissioned Personnel                                            550 C Street West, Suite 6                                                                                Office of the Director, Room 4A-15                                      Randolph AFB, TX 78150-4708                                                                                   5600 Fishers Lane Rockville, MD 20857-0001

APPLICATION FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

SECTION I - PERSONAL IDENTIFICATION

1. NAME (Last, First, Middle Initial)

2. MAILING ADDRESS AND CONTACT INFORMATION

a. STREET (Include apartment number)

3.a. SOCIAL SECURITY NUMBER

b. SERVICE NUMBER (If different)

b. CITY

c. STATE

d. ZIP CODE

4. DATE OF BIRTH (YYYYMMDD)

5. RETIRED RANK/PAY GRADE

6.a. UNIFORMED SERVICE FROM WHICH YOU RETIRED

e. DAYTIME TELEPHONE NO. (Include area code)

f. E-MAIL ADDRESS IOptional)

b. OTHER UNIFORMED SERVICE(S) IN WHICH YOU SERVED

7. YEAR RETIRED (YYYY)

8. DID YOU RETIRE UNDER MILITARY DISABILITY RETIREMENT PROVISIONS (Chapter 61 of Title 10, U.S. Code)?

YES

   NO

SECTION II - PRELIMINARY CRSC CRITERIA

NOTE:  You must meet ALL criteria of this section or your application will be denied.

9. ANSWER ONLY THE ONE PART THAT APPLIES TO YOUR RETIREMENT:

 a. FOR REGULAR OR DISABILITY RETIREMENTS ONLY.  Do you have 20 or more years of service creditable for the computation of the amount of your retired pay?

YES

   NO

b. FOR NON-REGULAR (RESERVE) RETIREMENT (Retired pay based on points) ONLY.

Did you have 7,200 points or more for the computation of retired pay?

YES

   NO

10. ARE YOU IN A RETIRED STATUS (i.e., are you on the retired rolls, or have you been transferred to the Fleet Reserve

or Fleet Marine Corps Reserve)?

Members recalled to, or retained on, active duty are not in a retired status during the period of such recall or retention.

YES

   NO

11. ARE YOU ENTITLED TO RETIRED PAY?

YES - Includes members who have waived military retired pay in order to receive VA disability compensation.

NO - Includes members who have waived military retired pay in order to credit military service for purposes of a civil

service retirement, or for any reason other than to receive disability compensation from the VA.

YES

   NO

12. ANSWER ALL PARTS:

a. Have you been awarded a Purple Heart AND do you receive VA disability compensation based on a combined disability rating of at least 10%?

YES

   NO

b. Do you receive VA disability compensation based on a current combined disability rating of at least 60%?

YES

   NO

c. Have you been awarded a Purple Heart AND did you receive a combined disability rating from the Secretary of a

Military Department, as of the date on which you retired from the Military Department, of at least 10%?

YES

   NO

d. Did you receive a combined disability rating from the Secretary of a Military Department, as of the date on which

you retired from the Military Department, of at least 60%?

YES

   NO

If you answered Yes to Items 9, 10, 11, and at least one part of Item 12, you appear to meet the Preliminary CRSC

Criteria and you should continue to Section III. Otherwise, do not complete the application, but you may apply later if your

circumstances change and you meet the Preliminary CRSC Criteria.

SECTION III - FINAL CRSC CRITERIA

ORIGIN OF DISABILITIES COMPENSATED BY THE VA

Final CRSC criteria require either a Purple Heart related injury rated at or above 10%, or combat-related injuries with a

combined rating at or above 60%. If you believe you meet one of these Final CRSC Criteria, you should complete the

application. If you do not believe you meet one of these final criteria, you should not complete the application, but you may

apply later if your circumstances change and you believe you meet these Final CRSC Criteria.

In this section list your VA service-connected disabilities and provide information and codes that address the disability and

how it was incurred. The "Origin of Disability Codes" are fully defined at the end of this section. A four-digit Medical

Diagnosis Code from the VA Schedule of Rating Disabilities (VASRD) is associated with every VA disability. Begin on the first

Section III page with your first disability and use a separate block for each additional disability.

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Page 2 of _________ Pages

SECTION III - FINAL CRSC CRITERIA (Continued)

Complete this section to the best of your ability. If you are unable to answer any of these questions, enter "Don't Know"

or "DK". If necessary, list other disabilities on additional copies of this page, including your name and Social Security Number.

If you don't have extra copies of this page, use a blank piece of paper, list your full name and SSN, and label and enter the

information for Items 13.a.(1), a.(2), b., c., d., e., f., and g. Enter a page number for each page completed: Page ____ of _______

(e.g., if you have this and 3 additional pages, enter Page 1 of 4.)

NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

13. FOR EACH OF YOUR DISABILITIES THAT IS RATED BY THE VA, PROVIDE THE FOLLOWING INFORMATION:

(Complete one Item 13 block for each disability that is rated by the VA.)

(1)

a. (1) MEDICAL DIAGNOSIS CODE

           (4 digit code of VA award)

a. (2) PART OF BODY AFFECTED AND NATURE OF THE DISABILITY

b. CURRENT VA RATING OF THIS DISABILITY

c. ORIGIN OF DISABILITY CODE (see list below). Select the ONE code that BEST describes the circumstances under which the disability

was incurred. If it applies, use Purple Heart (PH) in preference to any other code.

ORIGIN OF DISABILITY CODES (Full definitions are provided at the end of this section below.)

NA - No other code applies

PH - Purple Heart Injury

AC - Armed Conflict

HS - Hazardous Service

SW - Performance of Duty Under

         Conditions Simulating War

IN    - Instrumentality of War

AO   - Agent Orange

GW  - Gulf War Service

RE - Radiation Exposure

MG - Mustard Gas or Lewisite

d. YEAR DISABILITY WAS INCURRED (YYYY) (Enter year of exposure for AO, GW, RE and MG)

,

e. WHERE THE DISABILITY WAS INCURRED (Name of installation or vessel, State or Region, and Country or Body of Water)

f. MILITARY UNIT TO WHICH YOU WERE ASSIGNED OR ATTACHED WHEN YOU INCURRED THE DISABILITY

g. BRIEFLY DESCRIBE THE DUTY YOU WERE PERFORMING WHEN YOU INCURRED THE DISABILITY. HOW WAS THE DISABILITY CAUSED BY THE COMBAT-RELATED CIRCUMSTANCES YOU ENTERED FOR ITEM c. ABOVE?

COMPLETE ADDITIONAL BLOCKS OF ITEM 13 AS NECESSARY, OR PROCEED TO ITEMS 14 AND 15.

(2)

a. (1) MEDICAL DIAGNOSIS CODE

(4 digit code of VA award)

a. (2) PART OF BODY AFFECTED AND NATURE OF THE DISABILITY

b. CURRENT VA RATING OF THIS DISABILITY

c. ORIGIN OF DISABILITY CODE (see list below). Select the ONE code that BEST describes the circumstances under which the disability

was incurred. If it applies, use Purple Heart (PH) in preference to any other code.

ORIGIN OF DISABILITY CODES (Full definitions are provided at the end of this section below.)

NA - No other code applies

PH - Purple Heart Injury

AC - Armed Conflict

HS - Hazardous Service

SW - Performance of Duty Under

         Conditions Simulating War

IN    - Instrumentality of War

AO   - Agent Orange

GW  - Gulf War Service

RE - Radiation Exposure

MG - Mustard Gas or Lewisite

d. YEAR DISABILITY WAS INCURRED (YYYY)

(Enter year of exposure for AO, GW, RE, and MG)

e. WHERE THE DISABILITY WAS INCURRED (Name of installation or vessel, State or Region,

and Country or Body of Water)

f. MILITARY UNIT TO WHICH YOU WERE ASSIGNED OR ATTACHED WHEN YOU INCURRED THE DISABILITY

g. BRIEFLY DESCRIBE THE DUTY YOU WERE PERFORMING WHEN YOU INCURRED THE DISABILITY. HOW WAS THE DISABILITY CAUSED BY THE COMBAT-RELATED CIRCUMSTANCES YOU ENTERED FOR ITEM c. ABOVE?

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Page 3 of _____  Pages

CIRCUMSTANCES UNDER WHICH A DISABILITY IS INCURRED

PURPLE HEART (PH) - The disability resulted from an injury for which you were awarded the Purple Heart. This should be

associated with an incident involving armed conflict. Be sure to include a copy of your Purple Heart award certificate and/or

your DD 214 reflecting the award.

DIRECT RESULT OF ARMED CONFLICT (AC) - The disability was incurred in the line of duty as a direct result of armed

conflict. The fact that a member incurred the disability during a period of war or an area of armed conflict or while

participating in combat operations is not sufficient to support a combat-related determination. There must be a definite

causal relationship between the armed conflict and the resulting disability. Armed conflict includes a war, expedition,

occupation of an area or territory, battle, skirmish, raid, invasion, rebellion, insurrection, guerrilla action, riot, or any other

action in which Service members are engaged with a hostile or belligerent nation, faction, force, or terrorists. Armed conflict

may also include such situations as incidents involving a member while interned as a prisoner of war or while detained

against his or her will in custody of a hostile or belligerent force or while escaping or attempting to escape from such

confinement, prisoner of war, or detained status.

WHILE ENGAGED IN HAZARDOUS SERVICE (HS) - Such service includes, but is not limited to, aerial flight, parachute duty,

demolition duty, experimental stress duty, and diving duty. A finding that a disability is the result of such hazardous service

requires that the disability be the direct result of actions taken in the performance of such service. Travel to or from such

service, or actions incidental to a normal duty status not considered hazardous are not included.

IN THE PERFORMANCE OF DUTY UNDER CONDITIONS SIMULATING WAR (SW). - In general this covers disabilities

resulting from military training, such as war games, practice alerts, tactical exercises, airborne operations, leadership reaction

courses, grenade and live fire weapons practice, bayonet training, hand-to-hand combat training, repelling, and negotiation of

combat confidence and obstacle courses. It does not include physical training activities such as calisthenics and jogging or

formation running and supervised sports activities.

INSTRUMENTALITY OF WAR (IN) - Incurrence during an actual period of war is not required. However, there must be a

direct causal relationship between the instrumentality of war and the disability. The disability must be incurred incident to a

hazard or risk of the service. An instrumentality of war is a vehicle, vessel, or device designed primarily for Military Service

and intended for use in such Service at the time of the occurrence or injury. It may also include such instrumentalities not

designed primarily for Military Service if use of, or occurrence involving, such instrumentality subjects the individual to a

hazard peculiar to Military Service. Such use or occurrence differs from the use or occurrence under similar circumstances in

civilian pursuits. A determination that a disability is the result of an instrumentality of war may be made if the disability was

incurred in any period of service as a result of such diverse causes as wounds caused by a military weapon, accidents

involving a military combat vehicle, injury or sickness caused by fumes, gases, or explosion of military ordnance, vehicles, or

material. For example, if a member is on a field exercise and is engaged in sporting activity and falls and strikes an armored

vehicle, the injury will not be considered to result from the instrumentality of war (armored vehicle) because it was the

sporting activity that was the cause of the injury, not the vehicle. On the other hand, if the individual was engaged in the

same sporting activity and the armored vehicle struck the member, the injury would be considered the result of an

inst