Whether or not you complete this form, you must submit one of the following based on the type of claim sought.
Where and when: please provide information about where and when the in-service traumatic event(s) occurred.
Approximate dates: VA will still review and consider all the evidence available to support your claim if you only provide approximate dates or locations.
Other individuals: if you provide name(s) of other individuals who were involved or present during the traumatic event(s), VA will not contact these individual(s).
Treatment records: VA has access to VAMC, CBOC, and MTF records.
Section VI: this section only applies if you checked personal traumatic event(s) (involving MST) in Item 8.
| Question | Answer |
|---|---|
| Form Name | VA Form 21-0781 |
| Form Length | 7 pages |
| Fillable? | Yes |
| Fillable fields | 130 |
| Avg. time to fill out | 22 min |
| Edition | Rev MAR 2024 |
| Where to send | Department of Veterans Affairs Evidence Intake Center |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | 21-0781, 0781, VA 21-0781, VA Form 21-0781, VA Form 0781, Statement in Support of Claimed Mental Health Disorder(s) |
| Official source | VA Form 21-0781 (Rev MAR 2024), Department of Veterans Affairs |
Va Form 21 0781 isn’t the one you’re looking for?