VA FORM
AUG 2004
21-4138
OMB Approved No. 2900-0075
Respondent Burden: 15 minutes
EXISTING STOCKS OF VA FORM 21-4138,
JUN 2000, WILL BE USED
SOCIAL SECURITY NO.
STATEMENT IN SUPPORT OF CLAIM
VA FILE NO.
C/CSS -
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)
The following statement is made in connection with a claim for benefits in the case of the above-named veteran:
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
SIGNATURE DATE SIGNED
ADDRESS
DAYTIME EVENING
TELEPHONE NUMBERS (Include Area Code)
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.
PRIVACY ACT INFORMATION: The 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, Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your
obligation to respond is required to obtain or retain benefits. 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. The requested information is
considered relevant and necessary to determine maximum benefits under the law. 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 obtain evidence in support of your claim for benefits (38 U.S.C. 501(a) and (b)). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 15 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.whitehouse.gov/omb/library/OMBINV.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or
suggestions about this form.
CONTINUE ON REVERSE
I AM REQUESTING A LETTER STATING THAT I AM RATED 100% PERMANENTLY AND TOTALLY DISABLED BY
THE U.S. DEPARTMENT OF VETERANS AFFAIRS AND THAT IT IS NOT DUE TO ENTITLEMENT FOR INDVIDUAL
UNEMPLOYABILITY.
THIS LETTER WILL BE PROVIDED TO THE COMMISSIONER OF THE REVENUE FOR A REAL ESTATE TAX
EXEMPTION FOR QUALIFIED DISABLED VETERANS. I REQUEST YOU ISSUE A LETTER SIMILAR TO THE
ATTACHED SAMPLE LETTER WHICH INCLUDES ALL REQUIRED INFORMATION.
