VA Form 21-22 "Appointment of Veterans Service Organization as Claimant's Representative"

What Is VA Form 21-22?

This is a legal form that was released by the U.S. Department of Veterans Affairs on February 1, 2019 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • 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 21-22 by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 21-22 "Appointment of Veterans Service Organization as Claimant's Representative"

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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 VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE
IMPORTANT: Please read the Privacy Act and Respondent Burden Information on Page 3 before
completing the form.
NOTE: If you prefer to have an individual assist you with your claim instead of a veterans service organization please complete VA Form 21-22,
Appointment of Individual as Claimant's Representative. When completed you can mail or fax this form to the appropriate intake center address
shown on Page 4. 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.
(First, Middle Initial, Last)
1. VETERAN'S NAME
2. VETERAN'S SOCIAL SECURITY NUMBER (SSN)
3. VA FILE NUMBER (If applicable)
4. VETERAN'S DATE OF BIRTH
Month
Day
Year
6. INSURANCE NUMBER(S) (If applicable) (Include letter prefix)
5. VETERAN'S SERVICE NUMBER (If applicable)
7. VETERAN'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
9. VETERAN'S EMAIL ADDRESS (Optional)
8. VETERAN'S TELEPHONE NUMBER (Include Area Code)
SECTION II: CLAIMANT'S INFORMATION (If other than veteran)
10. CLAIMANT'S NAME (First, Middle Initial, Last)
11. CLAIMANT'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
13. CLAIMANT'S EMAIL ADDRESS (Optional)
12. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)
14. RELATIONSHIP TO VETERAN
SECTION III: SERVICE ORGANIZATION INFORMATION
15. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on Page 3 before selecting
organization)
16A. NAME OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE
16B. JOB TITLE OF PERSON NAMED IN ITEM 16A
ORGANIZATION NAMED IN ITEM 15 (This is an appointment of the entire organization
and does not indicate the designation of only this specific individual to act on behalf of the
organization)
17. EMAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 15
18. DATE OF THIS APPOINTMENT (MM/DD/YYYY)
21-22
SUPERSEDES VA FORM 21-22, AUG 2015.
VA FORM
Page 1
FEB 2019
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 VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE
IMPORTANT: Please read the Privacy Act and Respondent Burden Information on Page 3 before
completing the form.
NOTE: If you prefer to have an individual assist you with your claim instead of a veterans service organization please complete VA Form 21-22,
Appointment of Individual as Claimant's Representative. When completed you can mail or fax this form to the appropriate intake center address
shown on Page 4. 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.
(First, Middle Initial, Last)
1. VETERAN'S NAME
2. VETERAN'S SOCIAL SECURITY NUMBER (SSN)
3. VA FILE NUMBER (If applicable)
4. VETERAN'S DATE OF BIRTH
Month
Day
Year
6. INSURANCE NUMBER(S) (If applicable) (Include letter prefix)
5. VETERAN'S SERVICE NUMBER (If applicable)
7. VETERAN'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
9. VETERAN'S EMAIL ADDRESS (Optional)
8. VETERAN'S TELEPHONE NUMBER (Include Area Code)
SECTION II: CLAIMANT'S INFORMATION (If other than veteran)
10. CLAIMANT'S NAME (First, Middle Initial, Last)
11. CLAIMANT'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
13. CLAIMANT'S EMAIL ADDRESS (Optional)
12. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)
14. RELATIONSHIP TO VETERAN
SECTION III: SERVICE ORGANIZATION INFORMATION
15. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on Page 3 before selecting
organization)
16A. NAME OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE
16B. JOB TITLE OF PERSON NAMED IN ITEM 16A
ORGANIZATION NAMED IN ITEM 15 (This is an appointment of the entire organization
and does not indicate the designation of only this specific individual to act on behalf of the
organization)
17. EMAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 15
18. DATE OF THIS APPOINTMENT (MM/DD/YYYY)
21-22
SUPERSEDES VA FORM 21-22, AUG 2015.
VA FORM
Page 1
FEB 2019
VETERAN'S SOCIAL SECURITY NUMBER
SECTION IV: AUTHORIZATION INFORMATION
19. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C. - By checking the
box below I authorize VA to disclose to the service organization named on this appointment form 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 service organization named in
Item 15 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 service organization
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 service organization named in Item 15, either by
explicit revocation or the appointment of another representative.
20. LIMITATION OF CONSENT- I authorize disclosure of records related to treatment for all conditions listed in Item 19 except:
DRUG ABUSE
INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)
ALCOHOLISM OR ALCOHOL ABUSE
SICKLE CELL ANEMIA
21. AUTHORIZATION TO CHANGE CLAIMANT'S ADDRESS - By checking the box below, I authorize the organization named in Item 15 to
act on my behalf to change my address in my VA records.
I authorize any official representative of the organization named in Item 15 to act on my behalf to change my address in
my VA records. This authorization does not extend to any other organization without my further written consent. This
authorization will remain in effect until the earlier of the following events: (1) I file a written revocation with VA; or (2) I
appoint another representative, or (3) I have been determined unable to manage my financial affairs and the individual or
organization named in Item 16A is not my appointed fiduciary.
I, the claimant named in Items 1 or 10, hereby appoint the service organization named in Item 15 as my representative to
prepare, present and prosecute my claim(s) for any and all benefits from the Department of Veterans Affairs (VA) based on the
service of the veteran named in Item 1. I authorize VA to release any and all of my records, to include disclosure of my Federal
tax information (other than as provided in Items 19 and 20), to my appointed service organization. I understand that my
appointed representative will not charge any fee or compensation for service rendered pursuant to this appointment. I understand
that the service organization I have appointed as my representative may revoke this appointment at any time, subject to 38 CFR
20.608. Additionally, in some cases a veteran's income is developed because a match with the Internal Revenue Service
necessitated income verification. In such cases, the assignment of the service organization as the veteran's representative is
valid for only five years from the date the claimant signs this form for purposes restricted to the verification match. Signed and
accepted subject to the foregoing conditions.
SECTION V: SIGNATURES
NOTE: THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
22B. DATE SIGNED (MM/DD/YYYY)
22A. SIGNATURE OF VETERAN OR CLAIMANT (Do Not Print)
23A. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 16A
23B. DATE SIGNED (MM/DD/YYYY)
(Do Not Print)
NOTE: As long as this appointment is in effect, the organization named herein will be recognized as the sole representative for
preparation, presentation and prosecution of your claim before the Department of Veterans Affairs in connection with your claim or
any portion thereof.
ACKNOWLEDGED
COPY OF VA FORM 21-22 SENT TO:
DATE SENT
REVOKED (Reason and date)
(Date)
VR&E FILE
EDU FILE
VA USE
ONLY
INSURANCE FILE
LG FILE
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.
Page 2
VA FORM 21-22, FEB 2019
RECOGNIZED SERVICE ORGANIZATIONS
Membership in an organization is not a prerequisite to appointment of the organization as claimant's representative.
The following is a listing of national, regional, or local organizations recognized by the Secretary of Veterans Affairs in the
preparation, presentation, and prosecution of claims under laws administered by the Department of Veterans Affairs.
African American PTSD Association
National Association of County Veterans Service Officers, Inc,
American Legion
National Association for Black Veterans, Inc.
American Red Cross
National Veterans Legal Services Program
AMVETS
National Veterans Organization of America
American Ex-Prisoners of War, Inc.
Navy Mutual Aid Association
American GI Forum, National Veterans Outreach Program
Paralyzed Veterans of America, Inc.
Armed Forces Services Corporation
Polish Legion of American Veterans, U.S.A.
Army and Navy Union, USA
Swords to Plowshares, Veterans Rights Organization, Inc.
Associates of Vietnam Veterans of America
The Retired Enlisted Association
Blinded Veterans Association
The Veterans Assistance Foundation, Inc.
Catholic War Veterans of the U.S.A.
The Veterans of the Vietnam War, Inc. & The Veterans
Disabled American Veterans
Coalition
Fleet Reserve Association
United Spanish War Veterans of the United States
Gold Star Wives of America, Inc.
United Spinal Association, Inc.
Italian American War Veterans of the United States, Inc.
Veterans of Foreign Wars of the United States
Jewish War Veterans of the United States
Veterans of World War I of the U.S.A., Inc.
Legion of Valor of the United States of America, Inc.
Vietnam Era Veterans Association
Marine Corps League
Vietnam Veterans of America
Military Officers Association of America (MOAA)
West Virginia Department of Veterans Assistance
Military Order of the Purple Heart
Wounded Warrior Project
National Amputation Foundation, Inc.
Although agency titles vary, the following States and possessions maintain veterans service agencies which are recognized to present
claims:
Alabama
Hawaii
Minnesota
North Dakota
Tennessee
American Samoa
Idaho
Mississippi
Northern Mariana Islands
Texas
Arizona
Illinois
Missouri
Ohio
Utah
Arkansas
Iowa
Montana
Oklahoma
Vermont
California
Kansas
Nebraska
Oregon
Virginia
Colorado
Kentucky
Nevada
Pennsylvania
Virgin Islands
Connecticut
Louisiana
New Hampshire
Puerto Rico
Washington
Delaware
Maine
New Jersey
Rhode Island
West Virginia
Florida
Maryland
New Mexico
South Carolina
Wisconsin
Georgia
Massachusetts
New York
South Dakota
Wyoming
Guam
Michigan
North Carolina
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, the requested information is considered relevant and necessary to recognize a service organization as your representative and/or identify
disclosable records. 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. 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 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 service organization you name to act on your behalf in the preparation, presentation, and
prosecution of claims for VA benefits (38 U.S.C. 5902). We will also use the information to identify any VA records that we may disclose to the service
organization (38 U.S.C. 5701(b)). 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.
Page 3
VA FORM 21-22, FEB 2019
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:
Mail your form to:
Mail your form to:
Department of Veterans Affairs
Department of Veterans Affairs
Claims Intake Center
Claims Intake Center
Attn: Milwaukee Pension Center
Attn: St. Paul Pension Center
P.O. Box 5192
P.O. Box 5365
Janesville, WI 53547-5192
Janesville, WI 53547-5365
Or fax your form to:
Or fax your form to:
Toll Free: (844) 655-1604
Toll Free: (844) 655-1604
This Pension Center Serves The Following:
This Pension Center Serves The Following:
Alabama
Arkansas
Illinois
Indiana
California
Alaska
Arizona
Colorado
Kentucky
Louisiana
Michigan
Mississippi
Hawaii
Idaho
Iowa
Kansas
Missouri
Ohio
Tennessee
Wisconsin
Minnesota
Montana
Nebraska
Nevada
New
North
Oklahoma
Oregon
Mail your form to:
Mexico
Dakota
Department of Veterans Affairs
South
Texas
Utah
Washington
Claims Intake Center
Dakota
Attn: Philadelphia Pension Center
Central
South
P.O. Box 5206
Wyoming
Mexico
America
America
Janesville, WI 53547-5206
Or fax your form to:
Caribbean
Toll Free: (844) 655-1604
This Pension Center Serves The Following:
Connecticut
Delaware
F
G
lorida
eorgia
New
Maine
Maryland
Massachusetts
Hampshire
North
New Jersey
New York
Pennsylvania
Carolina
Rhode
South
Vermont
Virginia
Island
Carolina
West
District of
Puerto Rico
Canada
Virginia
Columbia
Countries outside of North, Central or South America
VA Form 21-22, FEB 2019
Page 4
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