Va Form 21 0845 – Fill Out and Use This PDF

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO

DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY

GENERAL INFORMATION

At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept confidential to the extent provided by law. In accordance with the Privacy Act and applicable confidentiality statutes, VA will only disclose the information in its custody or control in the following circumstances: where the individual identifies the particular information and consents to its use; where disclosure of the information is required by law; or where the disclosure is otherwise legally permitted, including release for a purpose compatible with the purpose for which it was collected.

By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit information for any purpose that is not permitted by all applicable legal authorities. You may revoke your written permission at any time, except if VA has already acted based on your permission.

WHERE DO I SEND MY COMPLETED WORK?

Send your signed authorization in by utilizing the following methods:

NOTE: You should make a copy of your signed authorization for your records before mailing it to VA. You can only have one VA Form 21-0845, Authorization to Disclose Personal Information to a Third Party, on file with VA at a time.

WHAT IF I CHANGE MY MIND?

If you change your mind and do not want VA to give out your personal benefit or claim information, you may notify us in writing, or by telephone at 1-800-827-1000 or electronically via the Internet at https://iris.custhelp.va.gov. Upon notification from you VA will no longer give out benefit or claim information (except for the information VA has already given out based on your permission).

OMB Approved No. 2900-0736 Respondent Burden: 5 minutes Expiration Date: 04/30/2022

SECTION I - VETERAN'S IDENTIFICATION INFORMATION

NOTE: You may either complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly to expedite processing the form.

1.VETERAN'S NAME (First, Middle Initial, Last)

5. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II - BENEFICIARY/CLAIMANT'S IDENTIFICATION INFORMATION

6.NAME OF BENEFICIARY/CLAIMANT WHO IS NOT THE VETERAN (First, Middle Initial, Last)

7.ADDRESS OF BENEFICIARY/CLAIMANT (Number and Street or rural route, P.O. Box, City, State, ZIP Code and Country)

8.TELEPHONE NUMBER (Include Area Code)

SECTION III - CONTACT INFORMATION

10.VA IS AUTHORIZED TO DISCLOSE THE INFORMATION SPECIFIED BELOW TO ONE PERSON OR ONE ORGANIZATION LISTED BELOW.

PROVIDE THE NAME AND ADDRESS OF THE PERSON YOU HAVE CHOSEN TO RECEIVE INFORMATION FROM VA IN ITEMS 10A AND 10B OR PROVIDE

THE NAME AND ADDRESS OF THE ORGANIZATION YOU HAVE CHOSEN AND THE NAME OF THE ORGANIZATION'S REPRESENTATIVE IN ITEMS 10C AND 10D.

A. NAME OF PERSON (First, Middle Initial, Last Name)

B. ADDRESS OF PERSON

No. &

Street

NOTE: An organization may have more than one representative. Include the first and last name of any additional representatives.

C. NAME OF ORGANIZATION (Include name of representative(s))

VETERAN'S SSN

D. ADDRESS OF ORGANIZATION

No. &

Street

11.I, THE BENEFICIARY/CLAIMANT AUTHORIZE VA TO CONTACT THE PERSON OR ORGANIZATION LISTED IN ITEM 10A OR 10C FOR THE PURPOSE OF PROVIDING THE FOLLOWING INFORMATION PERTAINING TO MY VA RECORD (Check only one box below to tell VA the specific benefit or claim information you want disclosed)

(Specify date - MM, DD, YYYY)

Ongoing until written notice is given to VA to terminate

14.SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY QUESTION BOX IN ITEM 14A AND PROVIDE THE ANSWER IN ITEM 14B.

The city and state your mother was born in

The name of the high school you attended

Your first pet's name

Your favorite teacher's name

Your father's middle name

SECTION IV - DECLARATION OF INTENT

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect.

RESPONDENT BURDEN: We need this information to release your private benefit and/or claim information to a designated third party(ies). The execution of this form does not authorize the release of information other than that specifically described. The information requested on this form will authorize release of the information you specify. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.