VA Form 119 Report of Contact

What Is VA Form 119?

VA Form 119, Report of Contact is an official document issued by the Department of Veterans Affairs (VA). It replaced VA Form 21-0820 (Report of General Information). The main purpose of the VA Report of Contact form is to document discussions that contain potentially controversial questions between the VA employees and claimants, their representatives, or other individuals.

Besides, this document is used to record important facts or information obtained by a VA employee. This information is used to supplement the veteran's record. If the individual states in future the VA employee has furnished incorrect or incomplete information, this form may be used to disprove the accusation. Here is the link to download VA Form 119 fillable version.

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REPORT OF CONTACT
NOTE: As appropriate, once this form is completed it becomes a permanent record in the veteran's folder. Please do not use a pencil to complete this form.
VA OFFICE
IDENTIFICATION NOS. (C,XC, SS, XSS, V, K, etc.)
LAST NAME-FIRST NAME-MIDDLE NAME OF VETERAN (Type or print)
DATE OF CONTACT
TELEPHONE NO. OF VETERAN (Include Area Code)
ADDRESS OF VETERAN
PERSON CONTACTED
TYPE OF CONTACT (check one)
PERSONAL
TELEPHONE
TELEPHONE NO. OF PERSON CONTACTED
ADDRESS OF PERSON CONTACTED
(Include Area Code)
PERSON WHO CONTACTED YOU
TYPE OF CONTACT (check one)
PERSONAL
TELEPHONE
ADDRESS OF PERSON WHO CONTACTED YOU
TELEPHONE NO. OF PERSON WHO
CONTACTED YOU (Include area code)
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (Continue on page 2 if needed)
EXECUTED BY (Signature and title)
DIVISION OR SECTION
VA FORM
119
SEP 1997 (R)
REPORT OF CONTACT
NOTE: As appropriate, once this form is completed it becomes a permanent record in the veteran's folder. Please do not use a pencil to complete this form.
VA OFFICE
IDENTIFICATION NOS. (C,XC, SS, XSS, V, K, etc.)
LAST NAME-FIRST NAME-MIDDLE NAME OF VETERAN (Type or print)
DATE OF CONTACT
TELEPHONE NO. OF VETERAN (Include Area Code)
ADDRESS OF VETERAN
PERSON CONTACTED
TYPE OF CONTACT (check one)
PERSONAL
TELEPHONE
TELEPHONE NO. OF PERSON CONTACTED
ADDRESS OF PERSON CONTACTED
(Include Area Code)
PERSON WHO CONTACTED YOU
TYPE OF CONTACT (check one)
PERSONAL
TELEPHONE
ADDRESS OF PERSON WHO CONTACTED YOU
TELEPHONE NO. OF PERSON WHO
CONTACTED YOU (Include area code)
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (Continue on page 2 if needed)
EXECUTED BY (Signature and title)
DIVISION OR SECTION
VA FORM
119
SEP 1997 (R)
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN
VA FORM 119, SEP 1997 (R), PAGE 2

Download VA Form 119 Report of Contact

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VA Form 119 Instructions

The VA Report of Contact is usually used in one of the following cases:

  • When some supplemental evidence related to a specific controversial case is obtained;
  • To perform a check when any complaints about a lack of service or actions taken by a VA employee are submitted;
  • To provide explanations and comments regarding any disallowances or other decisions when the veteran is not satisfied with them;
  • To provide the first notice of the beneficiary's death if the VA has not been noticed in any other way;
  • To explain facts that have led to either favorable or adverse decision regarding the individual's entitlement to specific VA benefits;
  • In special situations when it is necessary to initiate the immediate check.

The form can be used to document information received from the claimant by telephone or through personal contact. In case the claimant has a power of attorney, a copy of the VA 119 Form must be sent to the representative, and a record annotating that the copy was transferred to the power of attorney must be made on the claimant's file copy. It is not allowed to use this form as a written request of information. In this case, an appropriate letter should be sent.

How to Fill out VA Form 119?

Fill out the VA Form 119 in ink or on typewriter only. Forms completed in pencil will not be accepted, as the completed form becomes a permanent record and is added to the veteran's file. The VA report of contact includes the following fields:

  1. VA Office. Provide the number of the VA regional office;
  2. Identification Nos. Enter the identification number of the claim payee referring to the example provided in the form;
  3. Last Name - First Name - Middle Name of Veteran. Provide the name in full in the format indicated;
  4. Date of Contact. Enter the current date;
  5. Address of Veteran. Provide the mailing address of the veteran;
  6. Telephone No. of Veteran. Specify both home and work phone numbers of the veteran if applicable. Include area code when entering phone numbers;
  7. Person Contacted. Specify the person you have contacted regarding the matter;
  8. Type of Contact. Check the applicable box;
  9. Address of Person Contacted. Enter the address of the person you have contacted regarding the matter;
  10. Telephone No. of Person Contacted. Provide the phone number of the person you have contacted. Do not forget to include the area code;
  11. Brief Statement of Information Requested and Given. Briefly summarize the information you have requested and all the relevant information you have obtained;
  12. Division or Section. Specify your division or section;
  13. Executed by. Enter your signature and title.

Remember that each VA 119 Form must clearly describe the conditions or situation that emerged during the contact. In addition, it must enumerate the actions taken by the VA employee as a result of the contact.

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