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APPOINTMENT OF VETERANS SERVICE ORGANIZATION AS CLAIMANT'S REPRESENTATIVE (County of Fulton)

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BROWSE COUNTY OF FULTON (NY) FORMS

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SUPERSEDES VA FORM 21-22, OCT 2014,
WHICH WILL NOT BE USED.
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE
OMB Control No. 2900-0321
Respondent Burden: 5 minutes
Expiration Date: 08/31/2018
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)
VA
USE
ONLY
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
5. INSURANCE NUMBER(S) (Include letter prefix)
7. RELATIONSHIP TO VETERAN
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.
VA FORM
AUG 2015
21-22
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)
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
COPY OF VA FORM 21-22 SENT TO: REVOKED (Reason and date)
LG FILE
INSURANCE FILE
VR&E FILE
EDU FILE
ACKNOWLEDGED
(Date)
DATE SENT
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.
11. DATE OF THIS APPOINTMENT
A. DAYTIME
13. LIMITATION OF CONSENT - I authorize disclosure of records related to treatment for all conditions listed in Item 12 except:
B. EVENING
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.
3B. NAME AND JOB TITLE OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE ORGANIZATION NAMED IN ITEM 3A (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)
4. SOCIAL SECURITY NUMBER (OR SERVICE NUMBER, IF NO SSN)
6. NAME OF CLAIMANT (If other than veteran)
10. EMAIL ADDRESS (If applicable)
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.
17. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 3B (Do Not Print)18. DATE SIGNED
ALCOHOLISM OR ALCOHOL ABUSE
DRUG ABUSE
SICKLE CELL ANEMIA
INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)
3C. EMAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 3A
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.
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.
RECOGNIZED SERVICE ORGANIZATIONS
African American PTSD Association
American Legion
American Red Cross
AMVETS
American Ex-Prisoners of War, Inc.
American GI Forum, National Veterans Outreach Program
Armed Forces Services Corporation
Army and Navy Union, USA
Associates of Vietnam Veterans of America
Blinded Veterans Association
Catholic War Veterans of the U.S.A.
Disabled American Veterans
Fleet Reserve Association
Gold Star Wives of America, Inc.
Italian American War Veterans of the United States, Inc.
Jewish War Veterans of the United States
Legion of Valor of the United States of America, Inc.
Marine Corps League
Military Officers Association of America (MOAA)
Military Order of the Purple Heart
National Amputation Foundation, Inc.
National Association of County Veterans Service Officers, Inc.
National Association for Black Veterans, Inc.
National Veterans Legal Services Program
National Veterans Organization of America
Navy Mutual Aid Association
Paralyzed Veterans of America, Inc.
Polish Legion of American Veterans, U.S.A.
Swords to Plowshares, Veterans Rights Organization, Inc.
The Retired Enlisted Association
The Veterans Assistance Foundation, Inc.
The Veterans of the Vietnam War, Inc. & The Veterans
Coalition
United Spanish War Veterans of the United States
United Spinal Association, Inc.
Veterans of Foreign Wars of the United States
Veterans of World War I of the U.S.A., Inc.
Vietnam Era Veterans Association
Vietnam Veterans of America
West Virginia Department of Veterans Assistance
Wounded Warrior Project
Although agency titles vary, the following States and possessions maintain veterans service agencies which are recognized to present
claims.
Hawaii
Idaho
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
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.
Alabama
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Membership in an organization is not a prerequisite to appointment of the organization as claimant's representative.
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
VA FORM 21-22, AUG 2015
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.
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APPOINTMENT OF VETERANS SERVICE ORGANIZATION AS CLAIMANT'S REPRESENTATIVE (County of Fulton)

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Completed 13 February 2021

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