Form Approved: OMB No. 2900-0028
Respondent Burden: 7.5 minutes
REQUEST FOR AND CONSENT TO RELEASE OF INFORMATION FROM INDIVIDUAL'S RECORDS
PRIVACY ACT STATEMENT: The execution of this form does not authorize the release of information other than that specifically described below.
The information requested on this form is solicited under Title 38, United States Code, and will authorize release of the information you specify. The
information may also be disclosed outside VA as permitted by law to include disclosure as stated in the "Notices of Systems of VA Records" published in
the Federal Register in accordance with the Privacy Act of 1974.
RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond, to this collection of information unless it
displays a valid OMB Control Number. The Privacy Act of 1974 (5 U.S.C. 552a) and VA's confidentiality statute (38 U.S.C. 5701) as implemented by 38
CFR 1.526(a) and 38 CFR 1.576(b) require individuals to provide written consent before documents or information can be disclosed to third parties not
allowed to receive records or information under any other provision of law. The information requested is approved under OMB Control Number
2900-0028 and is necessary to ensure that the statutory requirements of the Privacy Act and VA's confidentiality statute are met.
Responding to this collection of information is voluntary. However, if the information is not furnished, we may not be able to comply with your request.
Public reporting burden for this collection is estimated to average 7.5 minutes per respondent, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspects of this collection of Information, including suggestions for reducing this burden, to the VA Clearance Officer
(005E3), 810 Vermont Avenue, NW, Washington, DC 20420. Send comments only. Do not send this form or requests for benefits to this address.
TO
Department of Veterans Affairs
NAME OF INDIVIDUAL (Type or print)
VA FILE NO. (Include prefix)
SOCIAL SECURITY NUMBER
NAME AND ADDRESS OF ORGANIZATION OR INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
VETERAN'S REQUEST
I hereby request and authorize the Department of Veterans Affairs to release the following
information from the records identified above to the organization, agency, or individual named
hereon:
NAME
INFORMATION REQUESTED (Number each item requested and give the dates or approximate dates - period from and to - covered by each.)
PURPOSE(S) FOR WHICH THE INFORMATION IS TO BE USED.
NOTE: Additional information may be listed on the reverse side of this form.
SIGNATURE OF INDIVIDUAL OR PERSON AUTHORIZED TO SIGN FOR INDIVIDUAL (Attach authority to sign, e.g., POA)
DATE
VA FORM
OCT 1995(R)
3288
