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INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE (Senior Veterans Service Alliance)

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GENERAL INFORMATION
INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO
DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY
SPECIFIC INSTRUCTIONS
Questions 1 - 5
In this section, give us the veteran's identification information to include name, social security number, VA file number, date
of birth and the veteran's service number, if applicable.
Questions 6 - 9
In this section provide the beneficiary/claimant's identification information.
Questions 10 - 13
This section tells VA the duration of your consent. If you do not want your authorization to be effective indefinitely, tell us
when to stop releasing your personal benefit or claim information to your authorized third party in Item 12. Check the box that
applies and fill in dates, if applicable.
In Item 13 VA will give your personal benefit or claim information to the person or organization you fill in here. You may
select only one person or one organization. If you designate an organization, you must also identify one or more
individuals in that organization to whom VA may disclose your benefit or claim information. This form cannot be used to
disclose federal tax information to third parties.
Important: The information provided in Item 6, "Name of Beneficiary/Claimant Who Is Not the Veteran" cannot be the same
information provided in Item 13.
Question 14
Select the security question you would like us to ask your designated third party and provide the answer. This question will
be asked each time your designated third party contacts our office.
Where Do I Send My Completed Form?
You can obtain the VA mailing address to send your completed, signed authorization by accessing our Internet website
at http://www.va.gov/directory or in the government pages of your telephone book under "United States Government,
Veterans."
You should make a copy of your signed authorization for your records before mailing it to VA. You can only have one active
VA Form 21-0845 on file with VA at a time.
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want VA to give out your personal benefit or claim information, you may notify us in
writing, or by telephone at 1-800-827-1000 or electronically via the Internet at https://iris.va.gov. Upon notification from you
VA will no longer give out benefit or claim information (except for the information VA has already given out based on your
permission).
VA FORM
SEP 2016
21-0845
At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept confidential to the
extent provided by law. In accordance with the Privacy Act and applicable confidentiality statutes, VA will only disclose the
information in its custody or control in the following circumstances: where the individual identifies the particular information
and consents to its use; where disclosure of the information is required by law; or where the disclosure is otherwise legally
permitted, including release for a purpose compatible with the purpose for which it was collected.
By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit information for any
purpose that is not permitted by all applicable legal authorities. You may revoke your written permission at any time, except if
VA has already acted based on your permission.
PAGE 1
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION
TO A THIRD PARTY
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)
OMB Approved No. 2900-0736
Respondent Burden: 5 minutes
Expiration Date: 09/30/2019
INSTRUCTIONS: Use this form if you want to give the Department of Veterans Affairs permission to release your personal
beneficiary or claim information to a third party. This form may not be executed by any beneficiary recognized as incompetent for
VA purposes, nor can VA accept this form from any beneficiary recognized as incompetent for VA purposes.
6. NAME OF BENEFICIARY/CLAIMANT WHO IS NOT THE VETERAN (First, Middle Initial, Last)
10. I (beneficiary/claimant) authorize the Department of Veterans Affairs (VA) to contact the person or organization listed below for the purposes 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)
Any Information (Go to Item 12)
From the date of signing below until
Request a benefit payment letter
7. ADDRESS OF BENEFICIARY/CLAIMANT
(Number and Street or rural route, P.O. Box, City, State, ZIP Code and Country)
Limited Information (Go to Item 11)
Payment history Change of address or direct deposit
Other Amount of money owed VA
11. IF YOU SELECTED "LIMITED INFORMATION", CHECK ALL THAT APPLY
One time only
Ongoing until written notice is given to VA to terminate
(Specify date - month, day, year)
Current benefit and rate
Status of pending claim or appeal
12. IF YOU SELECTED "ANY INFORMATION", THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE:
1. NAME OF VETERAN
(First, Middle Initial, Last)
3. VA FILE NUMBER
VA FORM
SEP 2016
SUPERSEDES VA FORM 21-0845, MAY 2015, WHICH
WILL NOT BE USED.
21-0845
PAGE 2
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly, and legibly to help process the form.
4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
2. VETERAN'S SOCIAL SECURITY NUMBER
5. VETERAN'S SERVICE NUMBER (If applicable)
YearDayMonth
SECTION II - BENEFICIARY/CLAIMANT'S IDENTIFICATION INFORMATION
No. &
Street
Apt./Unit Number
City
ZIP Code/Postal Code
State/Province
Country
8. PREFERRED PHONE NUMBER (Include Area Code)
9. PREFERRED EMAIL ADDRESS (Optional)
SECTION III - CONTACT INFORMATION
A. NAME OF PERSON OR ORGANIZATION
13. VA IS AUTHORIZED TO DISCLOSE THE INFORMATION AS SPECIFIED ABOVE TO THE PERSON OR ORGANIZATION LISTED BELOW.
NOTE: IF AUTHORIZATION IS FOR AN ORGANIZATION, PLEASE PROVIDE THE FIRST AND LAST NAME OF THE ORGANIZATION'S REPRESENTATIVE.
B. ADDRESS OF PERSON OR ORGANIZATION
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.
15B. DATE SIGNED
Your father's middle name
14. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY.
CHECK ONLY ONE SECURITY QUESTION BOX IN 14A AND PROVIDE THE ANSWER IN 14B.
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
15A. SIGNATURE (Do NOT print)
VA FORM 21-0845, SEP 2016
SECTION III - CONTACT INFORMATION (Continued)
PAGE 3
SECTION IV - DECLARATION OF INTENT
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
VETERAN'S SSN
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INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE (Senior Veterans Service Alliance)

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Completed 24 August 2020

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