SGLV Form 8284a
TSGLI Servicemember/Veteran Statement
Who fills it
veteran
Journey phase
Evidence & Statements
Estimated time
20-30 minutes.
When to file
With SGLV 8284.
You are filing a TSGLI claim (SGLV 8284) and need to provide your own statement of the event and losses.
Gather before you start
—Your account of the traumatic event
—Description of how your losses affect daily function
Section I - Service Member Identification
Blocks 1-3Name, SSN, TSGLI claim numberPII
Your identifying information and the TSGLI claim number from SGLV 8284.
Example
(legal name, SSN, TSGLI claim number)
Common mistakes
- Not including the TSGLI claim number - statement cannot be matched to the primary claim.
Section II - Personal Statement
Block 4First-person account of injury and functional losses
Describe in your own words: (1) What happened during the traumatic event, (2) What specific losses you sustained (vision, hearing, limb, ADL limitations), (3) How these losses affected your ability to care for yourself in the days, weeks, and months after the injury. Be specific about ADL limitations if claiming that category - note how many consecutive days you could not bathe, dress, eat, toilet, or transfer independently.
Example
e.g., On 03/15/2021 while conducting a patrol near Kandahar, the vehicle I was riding in struck an IED. I was thrown from the vehicle and sustained traumatic amputation of my right hand. For the next 60 days I could not independently bathe, dress, or perform most ADLs without my wife's full assistance...
Common mistakes
- Being too brief - the more specific and detailed, the stronger the TSGLI claim.
- Not including exact dates and duration for ADL losses - "a few weeks" is weaker than "45 consecutive days from March 15 through April 29."
Authority
38 USC 1980A - Lump-sum TSGLI for qualifying losses (vision, limb, paralysis, ADLs).
Section III - Certification
Blocks 5-6Service member signature and datePII
Sign and date certifying accuracy under penalty of perjury.
Example
(signature/date)
Common mistakes
- Understating losses out of pride - document accurately, not modestly.
Statutory & regulatory authority
38 USC 1980A - Lump-sum TSGLI for qualifying losses (vision, limb, paralysis, ADLs).