I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
12. IF YOU SELECTED "LIMITED INFORMATION", FILL ALL THAT APPLY
A. SECURITY QUESTION
B. ANSWER
PRIVACY ACT INFORMATION: 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. 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. The 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.
RESPONDENT BURDEN: We need this information to release your private benefit and/or claim information to a designated third party(ies). The
execution of this form does not authorize the release of information other than that specifically described. The information requested on this form
will authorize release of the information you specify. 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.
16. DATE SIGNED (MM,DD,YYYY)
14. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY
QUESTION BOX IN ITEM 14A AND PROVIDE THE ANSWER IN ITEM 14B.
15. VETERAN SIGNATURE (Do NOT print)
VA FORM 21-0845, APR 2020
PAGE 3
SECTION IV - DECLARATION OF INTENT
VETERAN'S SSN
(Specify date - MM, DD, YYYY)
13. IF YOU SELECTED "ANY INFORMATION", THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE:
11. I, THE BENEFICIARY/CLAIMANT AUTHORIZE VA TO CONTACT THE PERSON OR ORGANIZATION LISTED IN ITEM 10A OR 10C FOR THE PURPOSE OF
PROVIDING THE FOLLOWING INFORMATION PERTAINING TO MY VA RECORD (Check only one box below to tell VA the specific benefit or claim information you
want disclosed)
D. ADDRESS OF ORGANIZATION
ZIP Code/Postal Code
Country State/Province
City Apt./Unit Number
No. &
Street
LIMITED INFORMATION (Go to Item 12)
ANY INFORMATION (Go to Item 13)
Status of pending claim or appeal
Current benefit and rate
Payment history
Amount of money owed VA
Request a benefit payment letter
Change of address or direct deposit
Other (Specify below)
One time only
Ongoing until written notice is given to VA to terminate
From the date of signing below until
The city and state your mother was born in
The name of the high school you attended
Your first pet's name
Your favorite teacher's name
Your father's middle name
