VA Form 21-4138 Statement in Support of Claim

What Is VA Form 21-4138?

VA Form 21-4138, Statement in Support of Claim is a form used to support a claim for benefits. This claim can be filed by the veteran or another person, such as a relative or a friend.

The latest edition of the form was released by the Department of Veterans Affairs (VA) in December 2017. The previous edition released in January 2015 is also being used. An up-to-date VA Form 21-4138 fillable version is available for digital filing and download below or can be found on the VA website.

The Statement in Support of Claim

The Statement in Support of Claim is a document where you provide information to substantiate your claim for receiving benefits. You can start your letter in the following way: "Dear Sir or Madam. Recently, I received benefits from the Department of Veterans Affairs. I am very grateful for this as it helps me afford the ongoing health care I need." Explain why you need the benefits and provide the supporting documentation. Your job is to find convincing arguments in support of what you are trying to achieve. If this is not the first time you are writing a statement, make sure this new statement is providing new information. Generally, it is a good idea to write one statement per claim and not to combine several claims under one statement.

What Is VA Form 21-4138 Used for?

The VA Form 21-4138 is a document that veterans, their families, friends, and former service members use to provide information in order to substantiate a claim for VA benefits.

ADVERTISEMENT

How to Fill out VA Form 21-4138?

The VA Form 21-4138 is distributed without filling guidelines provided on the form. Instructions for completing the form are provided below.

VA Form 21-4138 Instructions

  1. Section I, Veteran/Beneficiary's Identification Information. Enter your personal information including your contact information.
  2. Section II, Remarks. This section is for the statement in support of a claim. This is the most important section of VA Form 21-4138. A very detailed explanation addressing all of the required additional information the VA requires must be provided. All the claims should be covered. All supporting documentation should be attached to the form. The veteran's social security number should be entered on top of each page used.
  3. The statement in support of the claim might contain a detailed description of the situation, that caused the injury or severe mental condition. The veteran can provide information on how long the symptoms of their condition lasted, how they affected their lives. If the veteran is filing this form in connection with Post-Traumatic Stress Disorder, they might need to provide a description of the traumatic event and the way the PTSD affects their life. The description should be detailed, but not exaggerated. Descriptions of symptoms should contain specific examples.
  4. It is possible to use the VA Form 21-4138 for a so-called "Buddy Statement", which is a statement filed by another service member. Buddy statement might be a description of the injury itself or the way the injury affected the veteran, providing information on their behavior or capabilities before the incident took place. The Buddy Statement can support the main statement by confirming the location or date of the event. In cases, when the veteran cannot remember the details of the event, the Buddy Statement can make the event more clearly.
  5. Supportive statements can also be prepared by a friend, family member, spouse, or a co-worker. The person filing the supporting statement must be sure they have known the veteran before and after their military service and indicate this information on the form.
  6. It is also possible to use the assistance of an attorney to file the form.
  7. Section III, Declaration of Intent. Use this section for certification. By signing the form, the veteran or the beneficiary certifies, that all the provided information is true and correct. The person filing the form provides their signature and dates the form at the bottom of the page.

Where to Mail VA Form 21-4138?

The VA Form 21-4138 can be filled out and submitted online as a part of a claim using the VA website. Filing claims using the Veterans' On-Line Application (VONAPP) is no longer possible. Alternatively, the form can be submitted to a local VA office. Their addresses are listed on the VA website.



OMB Control No. 2900-0075
Respondent Burden: 15 minutes
Expiration Date: 12/31/2020
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
STATEMENT IN SUPPORT OF CLAIM
INSTRUCTIONS: Read the Privacy Act and Respondent Burden on Page 2 before completing the form. Complete as
much of Section I as possible. The information requested will help process your claim for benefits. If you need any
additional room, use the second page.
SECTION I: VETERAN/BENEFICIARY'S IDENTIFICATION INFORMATION
NOTE: You will either complete the form online or by hand. Please print the information request in ink, neatly, and legibly to help process the form.
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VA FILE NUMBER (If applicable)
Month
Day
Year
5. VETERAN'S SERVICE NUMBER (If applicable)
7. E-MAIL ADDRESS (Optional)
6. TELEPHONE NUMBER (Include Area Code)
8. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
SECTION II: REMARKS
(The following statement is made in connection with a claim for benefits in the case of the above-named veteran/beneficiary.)
VA FORM
EXISTING STOCKS OF VA FORM 21-4138, JAN 2015,
Page 1
21-4138
DEC 2017
WILL BE USED.
OMB Control No. 2900-0075
Respondent Burden: 15 minutes
Expiration Date: 12/31/2020
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
STATEMENT IN SUPPORT OF CLAIM
INSTRUCTIONS: Read the Privacy Act and Respondent Burden on Page 2 before completing the form. Complete as
much of Section I as possible. The information requested will help process your claim for benefits. If you need any
additional room, use the second page.
SECTION I: VETERAN/BENEFICIARY'S IDENTIFICATION INFORMATION
NOTE: You will either complete the form online or by hand. Please print the information request in ink, neatly, and legibly to help process the form.
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VA FILE NUMBER (If applicable)
Month
Day
Year
5. VETERAN'S SERVICE NUMBER (If applicable)
7. E-MAIL ADDRESS (Optional)
6. TELEPHONE NUMBER (Include Area Code)
8. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
State/Province
Country
ZIP Code/Postal Code
SECTION II: REMARKS
(The following statement is made in connection with a claim for benefits in the case of the above-named veteran/beneficiary.)
VA FORM
EXISTING STOCKS OF VA FORM 21-4138, JAN 2015,
Page 1
21-4138
DEC 2017
WILL BE USED.
VETERAN'S SOCIAL SECURITY NO.
SECTION II: REMARKS (Continued)
(The following statement is made in connection with a claim for benefits in the case of the above-named veteran/beneficiary.)
SECTION III: DECLARATION OF INTENT
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
(Sign in ink)
9. SIGNATURE
10. DATE SIGNED (MM/DD/YYYY)
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false.
PRIVACY ACT INFORMATION: The 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 required to obtain or retain benefits. 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. The requested information is considered relevant and necessary to determine maximum benefits under the law. 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 obtain evidence in support of your claim for benefits (38 U.S.C. 501(a) and (b)). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 15 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.
Page 2
VA FORM 21-4138, DEC 2017

Download VA Form 21-4138 Statement in Support of Claim

859 times
Rate
4.3(4.3 / 5) 26 votes
ADVERTISEMENT
Page of 2