RESPONDENT BURDEN: We need this information to identify and obtain the information you are requesting. 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.
VA Form 20-10206, OCT 2020
20A. REQUESTER'S SIGNATURE (REQUIRED)
20B. DATE SIGNED
NOTE: A third-party signature will not be accepted unless a valid VA Form 21-0845, Authorization to Disclose Personal Information to a Third Party is of
record or completed and attached to this request. A third-party may be a family member or other designated person who is not a Power of Attorney,
agent, or fiduciary.
I CERTIFY THAT I have completed this FOIA/PA request and declare it is true and correct to the best of my knowledge and belief.
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.
SECTION VI: REQUESTER CERTIFICATION AND SIGNATURE
SECTION VII: THIRD-PARTY CERTIFICATION AND SIGNATURE
(Valid only if Section II has been completed and requester has an authorized third party)
I CERTIFY THAT the requester has authorized me as the undersigned representative and certifies that the truth and completion of the
information contained in this document is to the best of the requesters knowledge and belief.
21A. THIRD-PARTY SIGNATURE
21B. DATE SIGNED
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.
SECTION VIII: POWER OF ATTORNEY (POA) CERTIFICATION AND SIGNATURE
(Valid only if Section II has been completed and requester has authorized POA representation)
I CERTIFY THAT the requester has authorized me as the undersigned representative and certifies the truth and completion of the information
contained in this document to the best of the requesters knowledge and belief.
22A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE)
22B. DATE SIGNED
NOTE: A POA's signature will not be accepted unless a valid VA Form 21-22, Appointment of Veterans Service Organization as Claimant's
Representative or VA Form 21-22a, Appointment of Individual as Claimant's Representative is of record or attached to this request.
SOCIAL SECURITY NUMBER