Fillable VBA-20-10208-ARE VA Form 20-10208

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VBA-20-10208-ARE VA Form 20-10208

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The VBA-20-10208-ARE VA Form 20-10208 form is 2 pages long and contains:

  • 3 signatures
  • 14 check-boxes
  • 62 other fields

Country of origin: US
File type: PDF

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15. IS THIS FORM BEING SUBMITTED IN RESPONSE TO A REQUEST YOU RECEIVED FROM VA?
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
DOCUMENT EVIDENCE SUBMISSION
VA FORM
APR 2020
20-10208
INSTRUCTIONS: Read the Privacy Act and Respondent Burden on Page 2 before completing this
form. This form is used for the submission of additional documentation or evidence in support of a
claim. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay
number is 711. VA forms are available at www.va.gov/vaforms.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
OMB Approved No. 2900-0877
Respondent Burden: 5 Minutes
Expiration Date: 07/31/2020
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help
expedite processing of the form.
7. E-MAIL ADDRESS
4. DATE OF BIRTH (MM-DD-YYYY)
3. VA FILE NUMBER (If applicable)
2. SOCIAL SECURITY NUMBER
1. VETERAN'S NAME (First, Middle Initial, Last)
6. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number
(If applicable)
PAGE 1
SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION
(If other than veteran)
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
5. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
14. E-MAIL ADDRESS
11. DATE OF BIRTH (MM-DD-YYYY)
10. VA FILE NUMBER (If applicable)
9. SOCIAL SECURITY NUMBER
8. CLAIMANTS NAME (First, Middle Initial, Last)
13. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number
(If applicable)
ZIP Code/Postal Code
Country
State/Province
City
Apt./Unit Number
No. &
Street
12. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
SECTION III: DOCUMENT/EVIDENCE TYPE YOU ARE SUBMITTING
YES NO
I agree to receive electronic correspondence from VA in regards to my claim.
I agree to receive electronic correspondence from VA in regards to my claim.
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.
PAGE 2
I CERTIFY THAT I have filled this form out completely and that it is true and correct to the best of my knowledge and belief.
18A.THIRD-PARTY SIGNATURE (Note: During COVID-19 ink and
electronic signatures are accepted)
16. IDENTIFY THE DOCUMENT(S) OR EVIDENCE YOU ARE SUBMITTING TO SUPPORT YOUR ESTABLISHED CLAIM.
BIRTH CERTIFICATE
DEATH CERTIFICATE
DIVORCE DECREE
DEPENDENCY INFORMATION
FINANCIAL INFORMATION
MARRIAGE CERTIFICATE
MEDICAL TREATMENT RECORDS
COURT PAPERS/DOCUMENTS
MILITARY PERSONNEL RECORDS
LAY STATEMENT (Describe)
SECTION IV: CERTIFICATION AND SIGNATURE
17A. VETERAN/CLAIMANT'S SIGNATURE (REQUIRED) (Note: During
COVID-19 ink and electronic signatures are accepted)
17B. DATE SIGNED (MM-DD-YYYY)
SECTION V: THIRD-PARTY SIGNATURE
(Valid only if requester has an authorized third-party)
18B. DATE SIGNED (MM-DD-YYYY)
I CERTIFY THAT the veteran/claimant has authorized me as the undersigned representative and certifies that the information contained in
this document is true and complete to the best of the veteran/claimant's knowledge. 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 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.
SECTION VI: POWER OF ATTORNEY (POA) SIGNATURE
(Valid only if requester has an authorized POA representation)
I CERTIFY THAT the veteran/claimant has authorized me as the undersigned representative and certifies that the information contained in
this document is true and complete to the best of veteran/claimant's knowledge.
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.
19B. DATE SIGNED (MM-DD-YYYY)
19A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE (Note: During COVID-19
ink and electronic signatures are accepted)
NOTE: You may select one or more type(s), depending on the type of documentation/evidence being provided with this form.
OTHER (Describe)
VETERAN/CLAIMANT'S SOCIAL SECURITY NO.
SERVICE TREATMENT RECORDS
20-10208
VA FORM
APR 2020
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.
RESPONDENT BURDEN: This information will let us help you in support of or response to your claim. 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.
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VBA-20-10208-ARE VA Form 20-10208

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Completed 8 May 2020

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