Fillable Fillable VA Form 21 10210 Buddy Letter Template With Examples

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Fillable VA Form 21 10210 Buddy Letter Template With Examples

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SECTION I: VETERAN'S IDENTIFICATION INFORMATION
LAY/WITNESS STATEMENT
VA FORM
AUG 2020
21-10210
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use this form to
submit a statement as a veteran/claimant or someone writing on your behalf to support a claim. If you or someone else
writing on your behalf are providing additional statement(s) to support your claim(s) please submit this form with your
application. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you
use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available at
www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center,
P.O. Box 4444, Janesville, WI, 53547-4444.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
OMB Approved No. 2900-0881
Respondent Burden: 10 Minutes
Expiration Date: 02/28/2021
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and completely
fill in each applicable circle to help expedite processing of the form.
8. E-MAIL ADDRESS
Year
Day
Month
4. DATE OF BIRTH
3. VA FILE NUMBER (If applicable)
2. SOCIAL SECURITY NUMBER
1. VETERAN'S NAME (First, Middle Initial, Last)
5. VA INSURANCE FILE NUMBER (If applicable)
PAGE 1
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
6. CURRENT MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
7. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number
(If applicable)
SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION
(Complete this section ONLY IF the claimant is NOT the veteran)
I agree to receive electronic correspondence from VA in regards
to my claim.
9. CLAIMANT'S NAME (First, Middle Initial, Last)
10. SOCIAL SECURITY NUMBER
11. VA FILE NUMBER (If applicable)
Year
Day
Month
12. DATE OF BIRTH
13. VA INSURANCE FILE NUMBER (If applicable)
14. RELATIONSHIP TO VETERAN (Check all that apply)
SERVED WITH CLAIMANT FAMILY/FRIEND OF CLAIMANT COWORKER/SUPERVISOR OF CLAIMANT
OTHER (Specify)
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
15. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
VA Form 21-10210, AUG 2020
PAGE 2
SECTION III: STATEMENT
(Use this section to submit your statement, or a statement from someone else writing on your behalf)
SOCIAL SECURITY NUMBER
I agree to receive electronic correspondence from VA in regards
to my claim.
17. E-MAIL ADDRESS
Enter International Phone Number
(If applicable)
16. TELEPHONE NUMBER (Include Area Code)
NOTE: If you would like to submit an additional statement on your own behalf or if you have more than one witness writing on your behalf, use a
separate form (VA Form 21-10210) for each statement.
18. STATEMENT (Note: Describe what you yourself know or have observed about the facts or circumstances relevant to this claim before VA)
SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION (Continued)
PART ONE: HOW DO YOU KNOW THE VETERAN?
In this first section, you need to explain how you know the Veteran.
Here is an example of how to write this section:
“My name is John Doe, and I’m the husband of veteran [INSERT VETERANS NAME]. I’m writing this statement on behalf
of veteran [INSERT VETERANS NAME]. I have known [VETERAN] since 1999, because we were high school
sweethearts. Over the past 20+ years, we have interacted daily.”
PART TWO: WHAT YOU WITNESSED OR ARE WITNESSING NOW
In this second section, you need to explain in detail what you witnessed or are witnessing in regard to the event or
incident. You do NOT need to explain every detail.
Here is an example of how to write this section:
“When I first met [VETERAN], before she entered active duty military service, she was happy, fun loving, and had no
mental health issues whatsoever. All of that changed in July 2004, when she was raped by another service member while
TDY to Lackland Air Force Base, San Antonio, Texas. It became very evident to me that she suffered from severe PTSD,
depression, and anxiety. I encouraged her to get help and seek treatment many times over the years, but because she
was an officer, and worked with senior military leaders, she was afraid of retaliation and reprisal.”
PART THREE: THE VETERAN'S CURRENT SEVERITY OF SYMPTOMS AND ANY WORK/LIFE IMPAIRMENT
In this final section, you need to explain the veteran’s current symptoms of the disability condition as YOU know them to
be. Again, you do NOT need to explain every detail, just the things you know about.
Here is an example of how to write this section:
“Throughout our marriage, I witnessed her suffer from severe depression, anxiety, dry mouth, insomnia, nightmares,
relationship problems, trust issues, severe anger, panic attacks 3-5x per week, memory problems, and sexual dysfunction,
among many others. The rape mentioned above by a fellow service member has affected her so much that it is my belief
she cannot have a normal relationship with anyone, anymore, which was a huge reason why we’ve had numerous marital
challenges over the years. I am 100% certain that her PTSD, depression, and anxiety are due to the rape.”
That's it.
You're not writing a novel here.
Keep it short and sweet.
Think LESS is MORE!
VA Form 21-10210, AUG 2020
PAGE 3
SECTION III: STATEMENT (Continued)
(Use this section to submit your statement, or a statement from someone else writing on your behalf)
SOCIAL SECURITY NUMBER
18. STATEMENT (Note: Describe what you yourself know or have observed about the facts or circumstances relevant to this claim before VA)
SECTION IV: WITNESS CONTACT INFORMATION
(Complete Section IV and V if the statement in Section III is from someone else writing on your behalf)
19. WITNESS NAME (First, Middle Initial, Last)
21. E-MAIL ADDRESS
Enter International Phone Number
(If applicable)
20. TELEPHONE NUMBER (Include Area Code)
SECTION V: CERTIFICATION OF STATEMENT AND SIGNATURE
I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.
22A. VETERAN/CLAIMANT/WITNESS SIGNATURE (REQUIRED)
Year
Day
Month
22B. DATE SIGNED
RESPONDENT BURDEN: This form is used to submit a statement that supports a claim already pending or already established with VA. Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 10 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, Vocational Rehabilitation and Employment Records - VA, published
in the Federal Register. Your obligation to respond is voluntary.
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact
knowing it to be false, or for fraudulent receipt of any document to which you are not entitled.
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Fillable VA Form 21 10210 Buddy Letter Template With Examples

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Completed 16 June 2021

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