VA Form 21-4193 "Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution"

What Is VA Form 21-4193?

This is a legal form that was released by the U.S. Department of Veterans Affairs on November 1, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of VA Form 21-4193 by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

ADVERTISEMENT
ADVERTISEMENT

Download VA Form 21-4193 "Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution"

1092 times
Rate (4.6 / 5) 66 votes
OMB Approved No. 2900-0116
Respondent Burden: 15 minutes
Expiration Date: 09-30-2020
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)
NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR
BENEFICIARY INCARCERATED IN PENAL INSTITUTION
NOTE: Pursuant to Title 38, U.S.C., 1505, 3482, 3680 and 5313, awards of Department of
Veterans Affairs benefits for veterans and beneficiaries are subject to adjustment or
discontinuance while such persons are incarcerated.
NAME AND ADDRESS OF INSTITUTION
FROM
TO
SECTION I: IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly, and legibly to help process the form.
(First, Middle Initial, Last)
2. VETERAN/BENEFICIARY's NAME
3. SOCIAL SECURITY NUMBER
4. VA FILE NUMBER
5. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
Day
Month
Year
7. RELATIONSHIP TO VETERAN
6. VETERAN'S SERVICE NUMBER (If applicable)
SECTION II: INFORMATION ABOUT INCARCERATION
10. DATE OF CONFINEMENT FOLLOWING CONVICTION
8. DATE OFFENSE WAS COMMITTED (MM/DD/YYYY)
9. TYPE OF OFFENSE FOR WHICH COMMITTED
(MM/DD/YYYY)
Month
Day
Year
Month
Year
Day
FELONY
MISDEMEANOR
11. LENGTH OF SENTENCE
12. SCHEDULED RELEASE DATE (MM/DD/YYYY)
Day
Year
Month
13A. IS INDIVIDUAL IN A WORK RELEASE OR HALFWAY HOUSE PROGRAM?
13B. DATE ENTERED PROGRAM (MM/DD/YYYY)
Day
Year
Month
YES
NO
SECTION III: REMARKS
EXISTING STOCK OF VA FORM 21-4193, JUN 2014,
VA FORM
21-4193
Page 1
NOV 2017
WILL BE USED.
OMB Approved No. 2900-0116
Respondent Burden: 15 minutes
Expiration Date: 09-30-2020
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)
NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR
BENEFICIARY INCARCERATED IN PENAL INSTITUTION
NOTE: Pursuant to Title 38, U.S.C., 1505, 3482, 3680 and 5313, awards of Department of
Veterans Affairs benefits for veterans and beneficiaries are subject to adjustment or
discontinuance while such persons are incarcerated.
NAME AND ADDRESS OF INSTITUTION
FROM
TO
SECTION I: IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly, and legibly to help process the form.
(First, Middle Initial, Last)
2. VETERAN/BENEFICIARY's NAME
3. SOCIAL SECURITY NUMBER
4. VA FILE NUMBER
5. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
Day
Month
Year
7. RELATIONSHIP TO VETERAN
6. VETERAN'S SERVICE NUMBER (If applicable)
SECTION II: INFORMATION ABOUT INCARCERATION
10. DATE OF CONFINEMENT FOLLOWING CONVICTION
8. DATE OFFENSE WAS COMMITTED (MM/DD/YYYY)
9. TYPE OF OFFENSE FOR WHICH COMMITTED
(MM/DD/YYYY)
Month
Day
Year
Month
Year
Day
FELONY
MISDEMEANOR
11. LENGTH OF SENTENCE
12. SCHEDULED RELEASE DATE (MM/DD/YYYY)
Day
Year
Month
13A. IS INDIVIDUAL IN A WORK RELEASE OR HALFWAY HOUSE PROGRAM?
13B. DATE ENTERED PROGRAM (MM/DD/YYYY)
Day
Year
Month
YES
NO
SECTION III: REMARKS
EXISTING STOCK OF VA FORM 21-4193, JUN 2014,
VA FORM
21-4193
Page 1
NOV 2017
WILL BE USED.
VETERAN'S SOCIAL SECURITY NO.
REMARKS (Continued)
SECTION IV: SIGNATURE OF OFFICIAL
14. NAME AND TITLE OF INSTITUTIONAL OFFICIAL
15. DATE SIGNED (MM/DD/YYYY)
17. INSTITUTION TELEPHONE NUMBER
16. SIGNATURE OF INSTITUTIONAL OFFICIAL (Sign in ink)
(Include Area Code)
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.
Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine the adjustment or discontinuance of VA benefits for veterans and beneficiaries who are incarcerated.
Title 38, United States Code 1505, 3482, 3680, and 5313, 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
http: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 21-4193, NOV 2017
DEPARTMENT OF VETERANS AFFAIRS
Where to Send Your Written Correspondence
In order to properly determine where to send your written correspondence, please first
identify your benefit type (Compensation, Veterans Pension, or Survivors Benefits); then,
locate the corresponding address based on your location of residence.
For correspondence relating to all Compensation claims:
Location of Residence
Address
All United States and Foreign Locations
Department Of Veterans
Affairs Evidence Intake Center
P.O. Box 4444
Janesville WI 53547-4444
Or fax your information to:
* Note: For foreign Veterans Pension and Survivors
Toll Free: 844-531-7818
Benefits please refer to the below addresses.
Local: 248-524-4260
For correspondence relating to all Veterans Pension and Survivors Benefits claims:
Location of Residence
Address
Alabama
Kentucky
Missouri
Department Of Veterans
Arkansas
Louisiana
Ohio
Affairs Claims Intake Center
Illinois
Michigan
Tennessee
Attention: Milwaukee Pension
Indiana
Mississippi
Wisconsin
Center
P.O. Box 5192
Janesville WI 53547-5192
Or Fax your information to:
Toll Free: (844) 655-1604
Alaska
Montana
Texas
Arizona
Nebraska
Utah
Department Of Veterans
California
Nevada
Washington
Affairs Claims Intake Center
Colorado
New Mexico
Wyoming
Attention: St. Paul Pension
Hawaii
North Dakota Mexico
Center
Idaho
Oklahoma
Central America
P.O. Box 5365
Iowa
Oregon
South America
Janesville WI 53547-5365
Kansas
South Dakota Caribbean
Or fax your information to:
Minnesota
Toll Free: (844) 655-1604
Department Of Veterans
Connecticut
New Hampshire
South Carolina
Delaware
New Jersey
Vermont
Affairs
Claims Intake Center
Florida
New York
Virginia
Attention: Philadelphia Pension
Georgia
North Carolina
West Virginia
Maine
Pennsylvania
District of Columbia
Center
P.O. Box 5206
Maryland
Rhode Island
Puerto Rico
Massachusetts
Canada
Janesville WI 53547-5206
Or fax your information to:
Toll Free: (844) 655-1604
Countries outside of North, Central or South America
Page 3
VA FORM 21-4193, NOV 2017
Page of 3