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AS CLAIMANT'S REPRESENTATIVE APPOINTMENT OF VETERANS SERVICE ORGANIZATION (U.S. Department of Veterans Affairs)

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14. RELATIONSHIP TO VETERAN
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE
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.
IMPORTANT: Please read the Privacy Act and Respondent Burden Information on Page 3 before
completing the form.
SECTION II: CLAIMANT'S INFORMATION (If other than veteran)
SUPERSEDES VA FORM 21-22, AUG 2015.
OMB Control No. 2900-0321
Respondent Burden: 5 minutes
Expiration Date: 02/28/2022
VA FORM
FEB 2019
21-22
SECTION I: VETERAN'S INFORMATION
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
1. VETERAN'S NAME (First, Middle Initial, Last)
2. VETERAN'S SOCIAL SECURITY NUMBER (SSN)
4. VETERAN'S DATE OF BIRTH
6. INSURANCE NUMBER(S) (If applicable) (Include letter prefix)
3. VA FILE NUMBER (If applicable)
12. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)
Year
Day
Month
5. VETERAN'S SERVICE NUMBER (If applicable)
NOTE: If you prefer to have an individual assist you with your claim instead of a veterans service organization, please complete VA Form 21-22a,
Appointment of Individual as Claimant's Representative. When completed you can mail this form to the appropriate address shown on Page 4.
VA forms are available at www.va.gov/vaforms.
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)
8. VETERAN'S TELEPHONE NUMBER (Include Area Code)
9. VETERAN'S EMAIL ADDRESS (Optional)
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
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)
16B. JOB TITLE OF PERSON NAMED IN ITEM 16A
17. EMAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 15
18. DATE OF THIS APPOINTMENT (MM/DD/YYYY)
Page 1
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
7. VETERAN'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
VA USE
ONLY
NOTE: THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
VA FORM 21-22, FEB 2019
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
VETERAN'S SOCIAL SECURITY NUMBER
Page 2
20. LIMITATION OF CONSENT- I authorize disclosure of records related to treatment for all conditions listed in Item 19 except:
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.
ALCOHOLISM OR ALCOHOL ABUSE
DRUG ABUSE
SICKLE CELL ANEMIA
INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)
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.
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.
SECTION IV: AUTHORIZATION INFORMATION
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
20.6. 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.
22A. SIGNATURE OF VETERAN OR CLAIMANT (Do Not Print)
22B. DATE SIGNED (MM/DD/YYYY)
23A. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 16A
(Do Not Print)
23B. DATE SIGNED (MM/DD/YYYY)
SECTION V: SIGNATURES
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.
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.
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
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:
Alabama
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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
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.
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.
Page 3
VA FORM 21-22, FEB 2019
Page 4
VA Form 21-22, FEB 2019
WHERE TO SEND YOUR WRITTEN CORRESPONDENCE
The time it takes your response to reach VA affects how long it takes to process your claim. We recommend
responding electronically whenever possible. Only claimants or representatives can upload responses
electronically currently. If you are not a claimant or representative, please send any correspondence to
the appropriate mailing address noted below.
The fastest way to respond to VA is to upload your response electronically through VA.gov.
Visit https://www.va.gov and under Disability click "Upload evidence to support your claim".
VA.gov provides one easy location to upload correspondence as well as learn about filing claims, check
claim status, find out how much money you have left to pay for school or training, or refill prescriptions and
communicate with your health care team among many items.
If you need to mail your correspondence, identify the benefit type; then, use the corresponding mailing
address below.
MAILING ADDRESSES:
Compensation Claims
Department of Veterans Affairs
Compensation Intake Center
P.O. Box 4444
Janesville, WI 53547-4444
Pension & Survivors Benefit Claims
Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, WI 53547-5365
Fiduciary
Department of Veterans Affairs
Fiduciary Intake
P.O. Box 95211
Lakeland, FL 33804-5211
Board of Veterans' Appeals
Department of Veterans Affairs
Board of Veterans' Appeals
P.O. Box 27063
Washington, DC 20038
These addresses serve all United States and foreign locations.
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AS CLAIMANT'S REPRESENTATIVE APPOINTMENT OF VETERANS SERVICE ORGANIZATION (U.S. Department of Veterans Affairs)

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Completed 7 November 2020

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