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

What Is VA Form 21-22?

VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, sometimes referred to as the VA Power of Attorney Form 21-22, is used if you prefer to have a service organization assist you with your claim. The Department of Veterans Affairs (VA) does not recognize the Powers of Attorney for the purposes of prosecuting a VA claim. In order to be recognized by the VA, a claimant's representative must be appointed according to the VA guidelines.

The form was released in August 2015 with several new features introduced to the electronic version of the form in February 2017. An up-to-date VA Form 21-22 fillable version is available for digital filing and can be downloaded below. It can also be found on the VA website.

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OMB Control No. 2900-0321
Respondent Burden: 5 Minutes
Expiration Date: 08/31/2018
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE
NOTE - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, "Appointment of Individual as Claimant's
Representative." VA Forms are available at www.va.gov/vaforms.
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.
1. LAST-FIRST-MIDDLE NAME OF VETERAN
2. VA FILE NUMBER (Include prefix)
3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)
National Association of County Veterans Service Officers (NACVSO) Cumberland County, NJ
(This is an appointment of the entire
3B. NAME AND JOB TITLE OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE ORGANIZATION NAMED IN ITEM 3A
organization and does not indicate the designation of only this specific individual to act on behalf of the organization)
Diana M Pitman, RN, BSN, VSO - Cumberland County Department of Veterans Affairs
3322 College Dr.,Office 228, PO Box 1500, Vineland, NJ 08362-1500
3C. E-MAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 3A
dianapi@co.cumberland.nj.us
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
4. SOCIAL SECURITY NUMBER (OR SERVICE NUMBER, IF NO SSN)
5. INSURANCE NUMBER(S) (Include letter prefix)
6. NAME OF CLAIMANT (If other than veteran)
7. RELATIONSHIP TO VETERAN
8. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
9. CLAIMANT'S TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME
B. EVENING
10. E-MAIL ADDRESS (If applicable)
11. DATE OF THIS APPOINTMENT
12. 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 3A 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 above, either by explicit revocation or the appointment of another representative.
13. LIMITATION OF CONSENT - I authorize disclosure of records related to treatment for all conditions listed in Item 12 except:
DRUG ABUSE
INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)
ALCOHOLISM OR ALCOHOL ABUSE
SICKLE CELL ANEMIA
14. AUTHORIZATION TO CHANGE CLAIMANT'S ADDRESS - By checking the box below, I authorize the organization named in Item 3A to act on my behalf
to change my address in my VA records.
I authorize any official representative of the organization named in Item 3A 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 3A is not my appointed fiduciary.
I, the claimant named in Items 1 or 6, hereby appoint the service organization named in Item 3A 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 12 and 13), 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.
THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
15. SIGNATURE OF VETERAN OR CLAIMANT (Do Not Print)
16. DATE SIGNED
17. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 3B (Do Not Print)
18. DATE SIGNED
ACKNOWLEDGED
REVOKED (Reason and date)
COPY OF VA FORM 21-22 SENT TO:
DATE SENT
VA
(Date)
VR&E FILE
EDU FILE
USE
ONLY
LG FILE
INSURANCE FILE
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.
VA FORM
21-22
SUPERSEDES VA FORM 21-22, OCT 2014,
COPY DESIGNATION
AUG 2015
WHICH WILL NOT BE USED.
OMB Control No. 2900-0321
Respondent Burden: 5 Minutes
Expiration Date: 08/31/2018
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE
NOTE - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, "Appointment of Individual as Claimant's
Representative." VA Forms are available at www.va.gov/vaforms.
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.
1. LAST-FIRST-MIDDLE NAME OF VETERAN
2. VA FILE NUMBER (Include prefix)
3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)
National Association of County Veterans Service Officers (NACVSO) Cumberland County, NJ
(This is an appointment of the entire
3B. NAME AND JOB TITLE OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE ORGANIZATION NAMED IN ITEM 3A
organization and does not indicate the designation of only this specific individual to act on behalf of the organization)
Diana M Pitman, RN, BSN, VSO - Cumberland County Department of Veterans Affairs
3322 College Dr.,Office 228, PO Box 1500, Vineland, NJ 08362-1500
3C. E-MAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 3A
dianapi@co.cumberland.nj.us
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
4. SOCIAL SECURITY NUMBER (OR SERVICE NUMBER, IF NO SSN)
5. INSURANCE NUMBER(S) (Include letter prefix)
6. NAME OF CLAIMANT (If other than veteran)
7. RELATIONSHIP TO VETERAN
8. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
9. CLAIMANT'S TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME
B. EVENING
10. E-MAIL ADDRESS (If applicable)
11. DATE OF THIS APPOINTMENT
12. 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 3A 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 above, either by explicit revocation or the appointment of another representative.
13. LIMITATION OF CONSENT - I authorize disclosure of records related to treatment for all conditions listed in Item 12 except:
DRUG ABUSE
INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)
ALCOHOLISM OR ALCOHOL ABUSE
SICKLE CELL ANEMIA
14. AUTHORIZATION TO CHANGE CLAIMANT'S ADDRESS - By checking the box below, I authorize the organization named in Item 3A to act on my behalf
to change my address in my VA records.
I authorize any official representative of the organization named in Item 3A 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 3A is not my appointed fiduciary.
I, the claimant named in Items 1 or 6, hereby appoint the service organization named in Item 3A 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 12 and 13), 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.
THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
15. SIGNATURE OF VETERAN OR CLAIMANT (Do Not Print)
16. DATE SIGNED
17. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 3B (Do Not Print)
18. DATE SIGNED
ACKNOWLEDGED
REVOKED (Reason and date)
COPY OF VA FORM 21-22 SENT TO:
DATE SENT
VA
(Date)
VR&E FILE
EDU FILE
USE
ONLY
LG FILE
INSURANCE FILE
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.
VA FORM
21-22
SUPERSEDES VA FORM 21-22, OCT 2014,
COPY DESIGNATION
AUG 2015
WHICH WILL NOT BE USED.
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 for Black Veterans, Inc.
American Legion
National Veterans Legal Services Program
American Red Cross
National Veterans Organization of America
AMVETS
Navy Mutual Aid Association
American Ex-Prisoners of War, Inc.
Paralyzed Veterans of America, Inc.
American GI Forum, National Veterans Outreach Program
Polish Legion of American Veterans, U.S.A.
Armed Forces Services Corporation
Swords to Plowshares, Veterans Rights Organization, Inc.
Army and Navy Union, USA
The Retired Enlisted Association
Associates of Vietnam Veterans of America
The Veterans Assistance Foundation, Inc.
Blinded Veterans Association
The Veterans of the Vietnam War, Inc. & The Veterans
Catholic War Veterans of the U.S.A.
Coalition
Disabled American Veterans
United Spanish War Veterans of the United States
Fleet Reserve Association
United Spinal Association, Inc.
Gold Star Wives of America, Inc.
Veterans of Foreign Wars of the United States
Italian American War Veterans of the United States, Inc.
Veterans of World War I of the U.S.A., Inc.
Jewish War Veterans of the United States
Vietnam Era Veterans Association
Legion of Valor of the United States of America, Inc.
Vietnam Veterans of America
Marine Corps League
West Virginia Department of Veterans Assistance
Military Officers Association of America (MOAA)
Wounded Warrior Project
Military Order of the Purple Heart
National Amputation Foundation, Inc.
National Association of County Veterans Service Officers, 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.
VA FORM 21-22, AUG 2015

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

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What Is VA Form 21-22 Used for?

While applying for VA benefits, a service member or a veteran can get help from a Veteran Service Organization (VSO). It is a veterans association that provides assistance for service members on terminal leave, veterans and their families in applying for VA benefits. The list of VSOs is included in the VA 21-22 form.

The form is a legitimate agreement between a claimant and an agency or a Service Organization, such as the Veterans of Foreign Wars (VFW), The American Legion or Vietnam Veterans of America, for a purpose of the permission to represent a veteran, to prepare and prosecute a claim before the VA.

After the form is been signed, the authorized party has access to the veteran's VA file and medical records. They can represent the veteran in court and at medical facilities.

There is a similar form called the VA Form 21-22A or "Appointment of Attorney or Agent as Claimant's Representative", for attorneys and agents, who may charge a fee for their services. No one can obtain information on a claim skipping filing one of these forms (also called a "third party authorization form"), as all of them contain the veteran's consent.

VA Form 21-22 Instructions

You need to have your Social Security Number (SSN) and a Service Number (SN) handy while filling out the form. A VA file number is typically the same as a social security number, though in some cases it is different. There are several ways to find out a VA Service Number:

  • check your correspondence with the VA;
  • call the VA Benefits or VA Education departments;
  • try using your Social Security Number, it works even if a file number is different.

The form should also meet the following requirements:

  • be signed by the claimant or the claimant's guardian,
  • in a case if the claimant is incompetent, minor, or otherwise incapacitated, the form can be filled out by the spouse, parent, other relative or friend, or the director of the hospital where health care, if provided;
  • the form should be submitted to the appropriate VA office.

How to Fill Out VA Form 21-22?

The form includes one page and a list of recognized service organizations. Instructions for VA Form 21-22 are as follows:

    • enter the name of the veteran and the VA file number;
    • enter the name of the organization chosen as their representative;
    • if the person who is filling out the form is not a veteran, provide their social security number, insurance number and your relationship to the veteran;
    • check the box to verify authorization and give consent to disclose medical records if needed.

Reminder for the form completion:

  • enough information to identify the veteran or claimant;
  • the name of the servant organization;
  • signature of the veteran or claimant with the date;
  • signature of a representative acting on behalf of the service organization with the date.

Filing Box 3B of VA Form 21-22 is optional. If completed, there is no need to verify that the specific representative listed in the box 3B is accredited. This form documents the appointment of the entire service organization listed in the Box 3A and does not limit action to a specific representative within the organization.

How to Revoke VA Form 21-22?

The VA 21-22 Form can be revoked at any time, and an agent or attorney may be discharged at any time. Unless a claimant specifically indicates otherwise, the receipt of a new POA completed by the claimant shall constitute a cancellation of an existing one.

The form is revoked by filing a written revocation with the VA. Fill out the VA 21-4138 Form to indicate that the current VSO representative is no longer requires as the veterans representative. A copy of the statement should be submitted by mail or hand delivery to both VA and the current representative. Another copy is kept by the claimant.

A new representative will probably want to review a claim carefully to offer the best guidance; this may take some time. Some VSO do not take representation when an appeal is active at the Board of Veterans Appeals.

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