CLAIM FOR COMBAT-RELATED SPECIAL COMPENSATION

CLAIM FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S. Code 1413a, as amended; E.O. 9397, November 1943 (SSN).

PRINCIPAL PURPOSE(S): Used by career retirees to submit a claim for Combat-Related Special Compensation (CRSC). Claim is

reviewed to determine eligibility for CRSC under 10 U.S.C. 1413a, and determine the amount and effective dates of payment.

ROUTINE USE(S): Information may be provided to the Department of Veterans Affairs (VA) for these purposes; to the Internal

Revenue Service (IRS) 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 claim for compensation.

DISCLOSURE: Voluntary; however, failure to provide any required information may result in member not being considered eligible

for CRSC.

GENERAL INSTRUCTIONS

Complete this form carefully and accurately.

To submit a valid claim you must complete the ENTIRE FORM and SIGN IT IN SECTION VI (bottom of Page 3). Unsigned claim

forms will not be processed.

Complete and submit this form (pages 1 - 3 ONLY) to apply for Combat-Related Special Compensation (CRSC). Print, type, or use a

computer and provide the best information available. If you do not know the answer, enter "Don't Know" or "DK". Do not leave any

item blank. You must identify the disabilities that you are claiming.

It is your responsibility to provide supporting documents from personal or government records, so make sure you supply all

documentation necessary to verify this claim.

If you need assistance completing this form, consult with the agency from which you retired (or another agency, as appropriate).

Army: http://www.crsc.army.mil/

Navy & Marine Corps: http://www.hq.navy.mil/corb/crscb/combatrelated.htm

Air Force: http://ask.afpc.randolph.af.mil

DoD: http://www.defenselink.mil/prhome/crsc.html

DFAS: http://www.dod.mil/dfas/retiredpay/combat-relatedspecialcompensationcrsc.html

Coast Guard: http://www.uscg.mil/hq/cgpc/adm/adm1.htm

Sign and date your claim. Enclose with your claim a clean legible copy of any supporting documents listed on page 3. Mail your claim

to the address listed below for the Uniformed Service from which you retired.

DO NOT SEND ANY ORIGINAL DOCUMENTS, AS THEY WILL NOT BE RETURNED.

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

ARMY:

U.S. Army Human Resources Command U.S.

ATTN: AHRC-DZB-CRSC

200 Stovall Street

Alexandria, VA 22332-0470

COAST GUARD:

Commander (adm-1-CRSC)

U.S. Coast Guard

Personnel Command

4200 Wilson Boulevard, Suite 1100

Arlington, VA 22203-1804

NAVY AND MARINE CORPS:

Secretary of the Navy

Council of Review Boards

ATTN: Combat Related Special Compensation Branch

720 Kennon Street SE, Suite 309

Washington Navy Yard, DC 20374-5023

NOAA CORPS:

Director, Commissioned Personnel Center

8403 Colesville Road, Suite 500

Silver Spring, MD 20910-6333

AIR FORCE:

United States Air Force

Disability Division (CRSC)

HQ AFPC/DPPDC

550 C Street West, Suite 6

Randolph AFB, TX 78150-4708

PUBLIC HEALTH SERVICE:

United States Public Health Service

Compensation Branch

Program Support Center, ESS

5600 Fishers Lane, Room 4-50

Rockville, MD 20857-0001

DD FORM 2860, APR 2008

General Purpose Sheet

PREVIOUS EDITION IS OBSOLETE.

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NOTE: If you answered NO to all questions a through d above, you are not eligible for CRSC.

CLAIM FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

SECTION I - PERSONAL INFORMATION

1. NAME (Last, First, Middle Initial)

2. SOCIAL SECURITY OR

EMPLOYEE ID NUMBER

3. RETIRED RANK/RATE

5. TELEPHONE (Include area code)4. DATE OF BIRTH (YYYYMMDD)

6. E-MAIL ADDRESS

7. MAILING ADDRESS

a. STREET (Include apartment number or P.O. Box)

b. CITY c. STATE

d. ZIP CODE

SECTION II - PRELIMINARY REQUIREMENTS

8. MARK (X) NEXT TO THE APPROPRIATE ANSWER FOR EACH QUESTION.

QUALIFICATION BEFORE JANUARY 1, 2008

YES NO

a. Were you entitled to retired pay for regular service, having completed at least 20 years of service prior to

January 1, 2008?

b. Were you entitled to retired pay for reserve service, having completed at least 20 years of combined active

and reserve service and having reached age 60 prior to January 1, 2008?

YES

QUALIFICATION ON OR AFTER JANUARY 1, 2008

YES NO

c. Were you entitled to retired pay for reserve service under the Reserve TERA program having completed at

least 15 but less than 20 years of combined active and reserve service and having reached age 60 prior to

January 1, 2008?

NOTE: You must provide proof of the retirement authority by attaching a copy of your Retirement Orders and/

or a copy of your 15 year letter. Evidence must clearly state that you were a reservist and you retired under

Section 12731a of title 10, United States Code.

d. Are you currently entitled to military retired pay for any reason, other than early reserve retirement for

physical disabilities not incurred in line of duty (i.e., other than section 12731b of title 10, United States

Code?

YES NO

DD FORM 2860, APR 2008

Page 1

SECTION III - SERVICE HISTORY

You must provide copies of evidence needed to verify this information (i.e., DD214's, awards, evaluations, etc.).

9. FROM WHICH SERVICE DID YOU RETIRE? Provide a copy of your

retirement orders or "retirement" DD214. To expedite this claim it

is important that you mail your claim to the service you retired from.

ARMY NAVY/USMC AIR FORCE

NOAA CORPS

PUBLIC HEALTHCOAST GUARD

10. DID YOU SERVE IN ANY OF THE FOLLOWING WARS OR COMBAT OPERATIONS? (X all that apply) (Provide a copy of a DD214/award

citation or any other evidence that verifies ANY combat service.)

WWI WWII VIETNAM

KOREAN

WAR

GULF

WAR

OTHER

(e.g., a SF Ops mission - explain where and when and

provide evidence.)

11. WERE YOU EVER A PRISONER OF WAR (POW)?

If YES, indicate Where/When/How long (Provide any official evidence available):

YES NO

OIF/OEF

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CLAIM FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

NAME (Last, First, Middle Initial)

SOCIAL SECURITY OR EMPLOYEE

ID NUMBER

NOTE: To ensure the review of all of your requested disabilities, limit ONE disability for each page. You are authorized to make

additional copies of this page for any additional disabilities. You may list any secondary conditions that are connected to a disability

on the bottom of the sheet that it has been connected to. In order to award any disability as secondary we must have a copy of the

evidence from VA or from your medical records which clearly states that the condition is the result of the primary condition you are

requesting. Good evidence could include a VA rating decision that clearly states (for example), "hypertension is secondary to

diabetes."

It is your responsibility to supply any evidence necessary to verify this disability is combat-related.

12. VA FILE NUMBER (If known)

SECTION IV - REQUEST FOR COMBAT-RELATEDNESS DETERMINATION

13. DISABILITY DESCRIPTION

g. COMBAT-RELATED CODE (Mark (X) the code that best describes what caused the disability.) (See Appendix A for code descriptions.)

PURPLE

HEART

ARMED

CONFLICT

HAZARDOUS

SERVICE

SIMULATING

WAR

INSTRUMENT

OF WAR

AGENT

ORANGE

RADIATION

GW or MG

GULF WAR or

MUSTARD GAS

a. TITLE OF DISABILITY (As written on the VA rating decision.) b. BODY PART AFFECTED. (e.g., right knee)

c. VA DISABILITY CODE (If known)

d. DATE AWARDED BY VA

(YYYYMMDD)

e. INITIAL RATING % BY THE VA

f. CURRENT RATING % BY

THE VA

h. UNIT OF ASSIGNMENT WHEN INJURED

j. IN YOUR OWN WORDS, DESCRIBE THE EVENTS SURROUNDING THE DISABILITY AND HOW IT MEETS THE GUIDELINES OF COMBAT-

RELATED.

YES

NO N/A

k. DID YOU RECEIVE A PURPLE HEART (PH) FOR THIS INJURY? If YES, attach documentation to verify that

you were awarded a PH and any evidence that proves what occurred or what body part was injured.

NOTE: Proof of being awarded a PH does not always allow us to award a disability as PH. We need to know

what the PH was awarded for. For example, send the medevac report and DD214.

YES NO

l. DID VA EVER DOCUMENT THAT THIS CONDITION CAUSED SECONDARY DISABILITIES? If YES, you

must provide evidence from VA or your medical records which state that the conditions listed in item 13.m.,

below, are indeed caused by the primary condition listed above. We cannot award any condition as secondary

without evidence to support the claim. Attach the VA rating decision for all secondary conditions.

NOTE: If YES, list all secondary conditions in item 13.m., below.

m. VA DETERMINED THAT THE FOLLOWING CONDITIONS ARE SECONDARY CONDITIONS TO THE PRIMARY DISABILITY (Listed in item

13.a., above).

(1) DISABILITY

CODE

(2) DESCRIPTION

(3) % AWARDED

BY VA

(4) DATE AWARDED

(YYYYMMDD)

DD FORM 2860, APR 2008

Page 2 - Sheet

i. LOCATION/AREA OF ASSIGNMENT WHEN INJURED

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SECTION V - REQUIRED DOCUMENTATION

14. In order to process your claim the following records (if applicable) must be submitted with this claim. Do not send ANY

original documents - COPIES only!

a. All DD214's and DD215's (especially if for retirement or showing combat ribbons).

b. Retirement orders and supporting documents.

d. Copies of ALL VA Rating Decisions, letters, and code sheets (current and prior). Do NOT remove any pages. All VA

documents discussing changes in benefits including Special Monthly Compensation (SCM) and/or Individual Unemployability

(IU).

c. Reserve Retirement point computation including any 15-year or 20-year letter (if applicable).

SECTION VI - CERTIFICATION AND WAIVER OF CONCURRENT RETIREMENT AND DISABILITY PAYMENTS (CRDP)

15. Complete this section to enable the Defense Finance and Accounting Service (DFAS) or the applicable pay center for

non-DoD retirees to make any CRSC payments you qualify to receive.

a. I understand that if I am eligible for both Concurrent Retirement and Disability Payments (CRDP) under 10 U.S.C., section

1414 and Special Compensation for Certain Combat-Related Disabled Uniformed Service Retirees under 10 U.S.C., section

1413a (CRSC), I may not receive both, but must elect which to receive.

b. I understand that if my election results in any retroactive payments, any previously paid amounts of CRDP, SCSD, or CRSC for

that period of time will be deducted from any amount due for that period.

c. Under penalties of perjury, the information provided above is true to the best of my knowledge and belief and provided with the

full knowledge of the penalties for making false statements (18 U.S.C. 287 and 1001 provide for a penalty of not more than

$10,000 fine, or 5 years in prison, or both; 31 U.S.C. 3279 provides civil penalties; and 31 U.S.C. 3802 provides administrative

penalties).

d. I hereby understand that payments will be deposited to my account of record for Uniformed Services retired pay if I am currently

receiving such payments. Otherwise, they will be made to the account of record for my VA disability compensation. After

payments begin, I must advise DFAS or the applicable non-DoD pay center of any changes to my account.

e. SIGNATURE

f. DATE SIGNED (YYYYMMDD)

DD FORM 2860, APR 2008

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e. Medical records or notes that verify how the injury/disability occurred. (Do NOT send EKGs, lab slips, CDs, diskettes or other

electronic media.)

f. Physical Evaluation Board (MEB-PEB) results and/or summaries.

NAME (Last, First, Middle Initial)

SOCIAL SECURITY OR EMPLOYEE

ID NUMBER

g. Any evidence which can be used to verify the events or circumstances.

CLAIM FOR COMBAT-RELATED SPECIAL COMPENSATION (CRSC)

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APPENDIX A - COMBAT-RELATED CODES

DD FORM 2860, APR 2008

Appendix A

PURPLE HEART (PH) - The disability resulted from an injury for which you were awarded the Purple Heart. Evidence should clearly show that the

injury was associated with an incident involving armed conflict, such as shrapnel wounds due to a mortar attack. Documentation must include a

copy of the Purple Heart citation and DD Form 214 reflecting the award and injury, or the Purple Heart citation, and excerpts from the Service

Medical Record that correspond to the date and document the treatment of the Purple Heart injury.

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 by itself to support a combat-related determination. There must be a definite, documented, 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.

IN THE PERFORMANCE OF DUTY UNDER CONDITIONS SIMULATING WAR (SW). - The disability was incurred in the line of duty as a

result of simulating armed conflict. The fact that a member incurred the disability during a period of simulating war or in an area of simulated

armed conflict or while participating in simulated combat operations is not sufficient by itself to support a combat-related determination. There

must be a definite, documented, causal relationship between the simulated armed conflict and the resulting disability. In general, this covers

disabilities resulting from simulated combat activity during military training, such as war games, practice alerts, tactical exercises, airborne

operations, grenade and live fire weapons practice, bayonet training, hand-to-hand combat training, rappelling, and negotiation of combat

confidence and obstacle courses while in full combat gear. Physical training activities such as calisthenics and jogging or formation running

and supervised sports activities are not included.

WHILE ENGAGED IN HAZARDOUS SERVICE (HS) - The disability was incurred during performance of duties that present a higher degree

of danger to Service personnel due to the level of exposure to actual or simulated armed conflict. The fact that a member incurred the

disability during a period of hazardous service is not sufficient by itself to support a combat-related determination. There must be a definite,

documented, causal relationship between the hazardous service and the resulting disability. Such service includes, but is not limited to, aerial

flight, parachute duty, demolition duty, experimental stress duty, diving duty, and rescue missions.

INSTRUMENTALITY OF WAR (IN) - The disability was incurred in the line of duty as a result of an instrumentality of war. 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. Incurrence during an actual period of war is not required; however, there must be a direct, documented, causal relationship between

the instrumentality of war and the resulting disability. The disability must be incurred incident to a hazard or risk of service and be caused by

the device itself. 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, are included. Such use or occurrence differs from the use or occurrence under similar

circumstances in civilian pursuits. An example of this would be injuries sustained while engaging in pugil stick training using a broomstick,

where the broomstick replaces the weapon and causes the injury. 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 instrumentality of war.

AGENT ORANGE (AO) - The disability was incurred as a result of Agent Orange exposure (herbicides). For these disabilities to be

considered combat related, they must be specifically granted by the Department of Veterans Affairs (VA) as presumptive to Agent Orange

exposure (herbicides). For consideration, the initial VA Rating Decision for the claimed disability must show not just Service connection, but

the specific causes of the condition; such as, member has Diabetes due to Agent Orange exposure (herbicides). In addition, for secondary

conditions to be granted as combat related, they must be specifically granted by the VA as secondary to the Agent Orange condition; such as,

member's Hypertension is secondary to Agent Orange Diabetes. If the conditions were diagnosed after Vietnam service and prior to

retirement, evidence must show the date of diagnosis and proof of Vietnam service. Proof of Vietnam service can include but is not limited to

service medical records, evaluations, decoration citations, travel vouchers or PCS orders.

RADIATION EXPOSURE (RE) - The disability was incurred as a result of combat-related radiation exposure. Combat-related radiation

exposure includes documented, onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of

Hiroshima or Nagasaki, Japan, by the United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946;

internment as a prisoner of war in Japan during World War II; or service in Paducah, Kentucky, Portsmouth, Ohio; or the area identified as

K25 at Oak Ridge, Tennessee for at least 250 days before February 1, 1992.

GULF WAR (GW), MUSTARD GAS OR LEWISITE (MG) - These codes relate to disabilities awarded by the VA on the basis of presumption

relating to service in the Persian Gulf War or exposure to Mustard Gas or Lewisite, even though there is no direct connection and the disability

did not occur immediately. For consideration, the initial VA Rating Decision for the claimed disability must show not just Service connection,

but the specific cause of the condition, such as, member has developed Fibromyalgia from service in the Persian Gulf War. Documentation

should also describe the place, period, and conditions of exposure. In addition, for secondary conditions to be granted as combat-related, they

must be specifically granted by the VA as secondary to the condition developed from service in the Persian Gulf War or exposure to Mustard

Gas or Lewisite; such as, member's Scars are secondary to Chronic Obstructive Pulmonary Disorder from exposure to Mustard Gas.

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