Fillable Form 21-22a APPOINTMENT OF INDIVIDUAL CLAIMANT'S REPRESENTATIVE

Fill Online, Printable, Fillable, Blank Form 21-22a APPOINTMENT OF INDIVIDUAL CLAIMANT'S REPRESENTATIVE Form

Use Fill to complete blank online U.S. DEPARTMENT OF VETERANS AFFAIRS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 21-22a APPOINTMENT OF INDIVIDUAL CLAIMANT'S REPRESENTATIVE

On average this form takes 13 minutes to complete

The Form 21-22a APPOINTMENT OF INDIVIDUAL CLAIMANT'S REPRESENTATIVE form is 2 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 46 other fields

Country of origin: US
File type: PDF

BROWSE U.S. DEPARTMENT OF VETERANS AFFAIRS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
SECTION I: VETERAN'S INFORMATION
SECTION II: CLAIMANT'S INFORMATION (If other than veteran)
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.
APPOINTMENT OF INDIVIDUAL AS
CLAIMANT'S REPRESENTATIVE
6. BRANCH OF SERVICE
11. CLAIMANT'S MAILING ADDRESS
(Number and street or rural route, city or P.O., State and ZIP Code)
15A. NAME OF INDIVIDUAL APPOINTED AS REPRESENTATIVE
15B. INDIVIDUAL IS (check appropriate box)
ATTORNEY
AGENT
SERVICE ORGANIZATION REPRESENTATIVE(Specify organization below)
18. ADDRESS OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE (Number and street or rural route, city or P.O., State, and ZIP code)
16A. SIGNATURE OF REPRESENTATIVE NAMED IN ITEM 15A
17A. SIGNATURE OF INDIVIDUAL NAMED IN ITEM 1 OR 10
*INDIVIDUALS PROVIDING REPRESENTATION UNDER SECTION 14.630
(Skip to Item 18, if the box for "Individual Providing Representation Under Section 14.630" was not checked in Item 15B)
The appointment of the individual named in Item 15A (the representative) authorizes that person to represent the individual named in Item 1 or 10 for a particular claim
pursuant to the provisions of 38 CFR 14.630. By our signatures below, we, the representative and the veteran/claimant, attest that no compensation will be charged by or
paid to the individual named in Item 15A.
VA FORM
FEB 2019
21-22a
OMB Control No. 2900-0321
Respondent Burden: 5 Minutes
Expiration Date: 02/28/2022
SUPERSEDES VA FORM 21-22a, AUG 2015.
Page 1
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
IMPORTANT: Please read the Privacy Act and Respondent Burden on Page 2 before completing the form.
NOTE: If you prefer to have a veterans service organization assist you with your claim instead of an individual please complete VA Form 21-22,
Appointment of Veterans Service Organization as Claimant's Representative. When completed you can mail or fax this form to the appropriate intake
center address shown on page 3. VA forms are available at www.va.gov/vaforms.
1. VETERAN'S NAME (First, Middle Initial, Last)
2. VETERAN'S SOCIAL SECURITY NUMBER (SSN)
4. VETERAN'S DATE OF BIRTH
3. VA FILE NUMBER (If applicable)
Year
Day
Month
5. VETERAN'S SERVICE NUMBER (If applicable)
10. CLAIMANT'S NAME
(First, Middle Initial, Last)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
ARMY
NAVY
AIR FORCE
MARINE CORPS COAST GUARD
OTHER
(Specify)
INDIVIDUAL PROVIDING REPRESENTATION
UNDER SECTION 14.630 (*See required statement
below. Signatures are required in Items 16A and 17A)
SECTION III: SERVICE ORGANIZATION INFORMATION
8. VETERAN'S TELEPHONE NUMBER (Include Area Code)
9. VETERAN'S EMAIL ADDRESS (Optional)
14. RELATIONSHIP TO VETERAN
12. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)
13. CLAIMANT'S EMAIL ADDRESS (Optional)
16B. DATE OF SIGNATURE (MM/DD/YYYY)
17B. DATE OF SIGNATURE (MM/DD/YYYY)
7. VETERAN'S MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code State/Province
Country
19. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C. -
Unless I check the box below, I do not authorize VA to disclose to the individual named in Item 15A 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.
CONDITIONS OF APPOINTMENT
I authorize the VA facility having custody of my VA claimant records to disclose to the individual named in Item 15A 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 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 individual named in Item 15A, either by explicit revocation or the
appointment of another representative.
I authorize the individual named in Item 15A to act on my behalf to change my address in my VA records. This authorization does not extend to
any other individual with out 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 individual named in Item 15A, either by
explicit revocation or the appointment of another representative.
20. LIMITATION OF CONSENT. My consent in Item 19 for the disclosure of records relating to treatment for drug abuse, alcoholism or alcohol abuse, infection
with the human immunodeficiency virus (HIV), or sickle cell anemia is limited as follows:
21. AUTHORIZATION FOR REPRESENTATIVE TO ACT ON CLAIMANT'S BEHALF TO CHANGE CLAIMANT'S ADDRESS -
Unless I check the box below, I do not authorize the individual named in Item 15A to act on my behalf to change my address in my VA records.
I, the person named in Item 1 or 10, hereby appoint the individual named in Item 15A as my representative to prepare,present, and prosecute my
claims for any and all benefits from the Department of Veterans Affairs (VA) based on the service of the veteran named in Item 1. If the individual
named in Item 15A is an accredited agent or attorney, the scope of representation provided before VA may be limited by the agent or attorney as
indicated below in Item 23. If the individual indicated in Item 15A is providing representation under 14.630, such representation is limited to a
particular claim only. I authorize VA to release any and all of my records (other than as provided in Items 19 and 20) to that individual appointed as
my representative, and if the individual in Item 15A is an accredited agent or attorney, this authorization includes the following individually named
administrative employees of my representative:
Signed and accepted subject to the foregoing conditions.
22A. SIGNATURE OF CLAIMANT (Do Not Print)
22B. DATE OF SIGNATURE (MM/DD/YYYY)
24B. DATE OF SIGNATURE (MM/DD/YYYY)24A. SIGNATURE OF REPRESENTATIVE
FEES: Section 5904, Title 38, United States Code, contains provisions regarding fees that may be charged, allowed, or paid for services of agents or attorneys in
connection with a proceeding before the Department of Veterans Affairs with respect to benefits under laws administered by the Department.
23. LIMITATIONS ON REPRESENTATION - AGENTS OR ATTORNEYS ONLY (Unless limited by an agent or attorney, this power of attorney revokes all
previously existing powers of attorney)
VA Form 21-22a, FEB 2019
Page 2
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, failure to respond provide the requested information could impede the recognition of your representative and/or
identification of disclosable records. Except for information protected by 38 U.S.C. 7332, your representative is not prohibited from redisclosing records. 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 individuals appointed by claimants to act on their behalf in the preparation, presentation, and prosecution of claims for
VA benefits (38 U.S.C. 5902, 5903, and 5904) and for those individuals to accept appointment. We will also use the information to verify consent for disclosure of VA records to the appointed
representative (38 U.S.C. 5701(b) and 7332) Title 38, United States Code, allows us to ask for this information. We estimate that claimants and individuals appointed for purposes of
representation will each 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. A Valid OMB control number 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.
VETERAN'S SOCIAL SECURITY NO.
SECTION IV: AUTHORIZATION INFORMATION
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.
South
America
Alaska Colorado
Utah
Georgia
Florida
New Jersey
Maryland
Delaware
This Pension Center Serves The Following:
This Pension Center Serves The Following:
California
This Pension Center Serves The Following:
Mail your form to:
Department of Veterans Affairs
Claims Intake Center
Attn: Milwaukee Pension Center
P.O. Box 5192
Janesville, WI 53547-5192
Or fax your form to:
Toll Free: (844) 655-1604
Texas
Alabama
Virginia
Connecticut
Maine
New
Hampshire
Mexico
Pennsylvania
Vermont
Arkansas
Caribbean
Oklahoma
Hawaii Idaho
Louisiana
Oregon
Nevada
Mississippi
New
Mexico
Illinois
Iowa
Indiana
Kansas
MichiganKentucky
Minnesota
Missouri
NebraskaMontana
North
Dakota
Ohio Tennessee
Wisconsin
Wyoming
Central
America
Washington
Mail your form to:
Department of Veterans Affairs
Claims Intake Center
Attn: St. Paul Pension Center
P.O. Box 5365
Janesville, WI 53547-5365
Or fax your form to:
Toll Free: (844) 655-1604
Arizona
Mail your form to:
Department of Veterans Affairs
Claims Intake Center
Attn: Philadelphia Pension Center
P.O. Box 5206
Janesville, WI 53547-5206
Or fax your form to:
Toll Free: (844) 655-1604
Massachusetts
New York
North
Carolina
Rhode
Island
South
Carolina
West
Virginia
District of
Columbia
Puerto Rico Canada
Countries outside of North, Central or South America
South
Dakota
FOR ALL COMPENSATION CLAIMS MAIL OR FAX THIS FORM TO THE FOLLOWING ADDRESS:
FOR VETERANS PENSION AND SURVIVOR BENEFIT CLAIMS MAIL OR FAX THIS FORM TO THE APPROPRIATE
ADDRESS SHOWN BELOW:
Mail your form to:
Department of Veterans Affairs
Claims Intake Center
P.O. Box 4444
Janesville, WI 53547- 4444
Or fax your form to:
Toll Free: (844) 531- 7818
Local: 248-524-4260
VA Form 21-22a, FEB 2019 Page 3
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 21-22a APPOINTMENT OF INDIVIDUAL CLAIMANT'S REPRESENTATIVE

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 January 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document