Va Form 21 22A – Fill Out and Use This PDF

OMB Control No. 2900-0321

Respondent Burden: 5 Minutes

Expiration Date: 02/28/2022

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPOINTMENT OF INDIVIDUAL AS

CLAIMANT'S REPRESENTATIVE

IMPORTANT: Please read the Privacy Act and Respondent Burden on Page 2 before completing the form.

NOTE: If you prefer to have a veterans service organization assist you with your claim instead of an individual please complete VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative. When completed you can mail OR fax this form to the appropriate intake center address shown on page 3. VA forms are available at www.va.gov/vaforms.

SECTION I: VETERAN'S INFORMATION

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

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

SECTION II: CLAIMANT'S INFORMATION (If other than veteran)

9.CLAIMANT'S NAME (First, Middle Initial, Last)

10.CLAIMANT'S MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)

No. &

Street

SECTION III: SERVICE ORGANIZATION INFORMATION

14A. NAME OF INDIVIDUAL APPOINTED AS REPRESENTATIVE

*INDIVIDUALS PROVIDING REPRESENTATION UNDER SECTION 14.630

(Skip to Item 17, if the box for "Individual Providing Representation Under Section 14.630" was not checked in Item 14B)

The appointment of the individual named in Item 14A (the representative) authorizes that person to represent the individual named in Item 1 or 9 for a particular claim pursuant to the provisions of 38 CFR 14.630. By our signatures below, we, the representative and the veteran/claimant, attest that no compensation will be charged by or paid to the individual named in Item 14A.

17.ADDRESS OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE (Number and street or rural route, city or P.O., State, and ZIP code)

VETERAN'S SOCIAL SECURITY NO.

SECTION IV: AUTHORIZATION INFORMATION

18. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C. -

Unless I check the box below, I do not authorize VA to disclose to the individual named in Item 14A any records that may be in my file relating to treatment for drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia.

I authorize the VA facility having custody of my VA claimant records to disclose to the individual named in Item 14A all treatment records relating to drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia. Redisclosure of these records by my representative, other than to VA or the Court of Appeals for Veterans Claims, is not authorized without my further written consent. This authorization will remain in effect until the earlier of the following events: (1) I revoke this authorization by filing a written revocation with VA; or (2) I revoke the appointment of the individual named in Item 14A, either by explicit revocation or the appointment of another representative.

19.LIMITATION OF CONSENT. My consent in Item 18 for the disclosure of records relating to treatment for drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia is limited as follows:

20.AUTHORIZATION FOR REPRESENTATIVE TO ACT ON CLAIMANT'S BEHALF TO CHANGE CLAIMANT'S ADDRESS -

Unless I check the box below, I do not authorize the individual named in Item 14A to act on my behalf to change my address in my VA records.

I authorize the individual named in Item 14A to act on my behalf to change my address in my VA records. This authorization does not extend to any other individual with out my further written consent. This authorization will remain in effect until the earlier of the following events: (1) I revoke this authorization by filing a written revocation with VA; or (2) I revoke the appointment of the individual named in Item 14A, either by explicit revocation or the appointment of another representative.

CONDITIONS OF APPOINTMENT

I, the person named in Item 1 or 9, hereby appoint the individual named in Item 14A as my representative to prepare,present, and prosecute my claims for any and all benefits from the Department of Veterans Affairs (VA) based on the service of the veteran named in Item 1. If the individual named in Item 14A is an accredited agent or attorney, the scope of representation provided before VA may be limited by the agent or attorney as indicated below in Item 23. If the individual indicated in Item 14A is providing representation under 14.630, such representation is limited to a particular claim only. I authorize VA to release any and all of my records (other than as provided in Items 18 and 19) to that individual appointed as my representative, and if the individual in Item 14A is an accredited agent or attorney, this authorization includes the following individually named administrative employees of my representative:

Signed and accepted subject to the foregoing conditions.

23.LIMITATIONS ON REPRESENTATION - AGENTS OR ATTORNEYS ONLY (Unless limited by an agent or attorney, this power of attorney revokes all previously existing powers of attorney)

FEES: Section 5904, Title 38, United States Code, contains provisions regarding fees that may be charged, allowed, or paid for services of agents or attorneys in connection with a proceeding before the Department of Veterans Affairs with respect to benefits under laws administered by the Department.

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material fact, knowing it to be false or for the fraudulent acceptance of any payment to which you are not entitled.

PRIVACY ACT NOTICE: 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. However, failure to respond provide the requested information could impede the recognition of your representative and/or identification of disclosable records. Except for information protected by 38 U.S.C. 7332, your representative is not prohibited from redisclosing records. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to recognize the individuals appointed by claimants to act on their behalf in the preparation, presentation, and prosecution of claims for VA benefits (38 U.S.C. 5902, 5903, and 5904) and for those individuals to accept appointment. We will also use the information to verify consent for disclosure of VA records to the appointed representative (38 U.S.C. 5701(b) and 7332) Title 38, United States Code, allows us to ask for this information. We estimate that claimants and individuals appointed for purposes of representation will each 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. A Valid OMB control number 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.

FOR ALL COMPENSATION CLAIMS MAIL OR FAX THIS FORM TO THE FOLLOWING ADDRESS:

Mail your form to:

Department of Veterans Affairs

Claims Intake Center

P.O. Box 4444

Janesville, WI 53547- 4444

Or fax your form to:

Toll Free: (844) 531- 7818

Local: 248-524-4260

FOR VETERANS PENSION AND SURVIVOR BENEFIT CLAIMS MAIL OR FAX THIS FORM TO THE APPROPRIATE ADDRESS SHOWN BELOW: