VA Form 21-0845: Authorization to Disclose Personal Information to a Third Party

Under 1-5, give the veteran's identification information to include name, social security number, VA file number, date of birth and the veteran's service number, if applicable.

Under 1. VETERAN'S NAME, enter First, Middle Initial, Last.

Under 2. VETERAN'S SOCIAL SECURITY NUMBER, enter the number; under 4. VETERAN'S DATE OF BIRTH, enter MM/DD/YYYY.

Under 3. VA FILE NUMBER, enter it if known.

Under 5. VETERAN'S SERVICE NUMBER, enter it if applicable.

Under 6-9, provide the beneficiary/claimant's identification information, who is not the veteran.

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

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

Under 8. TELEPHONE NUMBER, include Area Code; if applicable, enter the International Phone Number.

Under 9. EMAIL ADDRESS (Optional), enter the address; you may check I agree to receive electronic correspondence from VA in regards to my claim.

VA is authorized to disclose the information specified to one person or one organization: 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.

VA will give your personal benefit or claim information to the person or organization you enter in Item 10. You may select only one person or one organization. If you designate an organization, you must also identify one or more individuals in that organization to whom VA may disclose your benefit or claim information. This form cannot be used to disclose federal tax information to third parties.

Common mistake: The information provided in Item 6, name of beneficiary or claimant who is not the veteran, cannot be the same information provided in Item 10.

Under A. NAME OF PERSON, enter First, Middle Initial, Last Name; under B. ADDRESS OF PERSON, enter the address.

Under C. NAME OF ORGANIZATION, include name of representative(s). An organization may have more than one representative. Include the first and last name of any additional representatives.

Under D. ADDRESS OF ORGANIZATION, enter the address.

In Item 11, check only one box to tell VA the specific benefit or claim information you want disclosed: LIMITED INFORMATION (Go to Item 12) or ANY INFORMATION (Go to Item 13).

If you selected "LIMITED INFORMATION", check all that apply: Status of pending claim or appeal, Current benefit and rate, Amount of money owed VA, Request a benefit payment letter, Change of address or direct deposit, Payment history, or Other (Specify).

If you selected "ANY INFORMATION", the terms of such release of information will be: One time only, Ongoing until written notice is given to VA to terminate, or From the date of signing until the date you specify (MM/DD/YYYY).

Item 13 tells VA the duration of your consent. If you do not want your authorization to be effective indefinitely, tell VA when to stop releasing your personal benefit or claim information to your authorized third party in Item 13. Check the box that applies and fill in dates, if applicable.

In Item 14, 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, or Your father's middle name.

Select the security question you would like VA to ask your designated third party and provide the answer. This question will be asked each time your designated third party contacts the VA.

By signing you certify that the statements on this form are true and correct to the best of my knowledge and belief.

Under 16. DATE SIGNED, enter MM/DD/YYYY.

Sign under 15. VETERAN/BENEFICIARY/CLAIMANT'S SIGNATURE (REQUIRED).

Send your signed authorization by mail to Department of Veterans Affairs Evidence Intake Center PO Box 4444 Janesville, WI 53547-4444, or submit it online at VA gov: www.va.gov or by Direct Upload via access.va.gov.

This form may not be executed by any beneficiary recognized as incompetent for VA purposes, nor can VA accept this form from any beneficiary recognized as incompetent for VA purposes.