SECTION VII: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE
(NOTE: REQUIRED ONLY IF ITEM 17A IS BLANK)
SECTION VI: WITNESSES TO SIGNATURE
I/WE, the undersigned, hereby authorize the hospital OR physician shown in Items 12B, 13A and 14A to disclose and release to the
Department of Veterans Affairs any information that may have been obtained in connection with the physical examination or treatment
of the child.
I/WE, the undersigned, declare under penalty of perjury that the information provided is true and correct and that the child named in
Item 1 is the natural child of the person(s) named in Items 7A and/or 7B.
19A. SIGNATURE OF WITNESS (Sign in ink. If adult child or parent or custodian/guardian
signed above using an "X")
19B. PRINTED NAME AND ADDRESS OF WITNESS
17A. SIGNATURE OF ADULT CHILD OR PARENT OR CUSTODIAN/GUARDIAN
17B. DATE SIGNED (MM/DD/YYYY)
Page 4
VA FORM 21-0304, FEB 2020
SECTION V: CLAIM CERTIFICATIONS AND SIGNATURES
PRIVACY ACT NOTICE: VA will not disclose the information collected on this form to any source other than what has been authorized under the Privacy Act of
1974 or Title 5, Code of Federal Regulations 1.526 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 required in order to
obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 U.S.C. 5101 (c) (1). The
VA will not deny an individual benefit for refusing to provide your 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. Information that you furnish may be utilized in computer matching programs with other Federal or State agencies for the purpose of
determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program
administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine your eligibility for benefits for children with certain disabilities who are born of Vietnam veterans
or certain Thailand or Korea service veterans (38 U.S.C. chapter 18). Title 38, United States Code, allows us to ask for this information. We estimate that you will need
an average of 10 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.
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 the fraudulent acceptance of any payment to which you are not entitled.
20A. ALTERNATE SIGNER SIGNATURE (REQUIRED) (Sign in ink)
I certify that by signing on behalf of the claimant, that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on
behalf of aclaimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a
spouse or other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND,
that the claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to
certify that the statements made on the form are true and complete; OR, is physically unable to sign this form.
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that
VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant
if necessary. Examples of evidence which VA may request include: Social Security number (SSN) or Taxpayer Identification Number (TIN); a
certificate or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/time
stamp; copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and your
authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the
care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
20B. DATE SIGNED (MM/DD/YYYY)
18B. PRINTED NAME AND ADDRESS OF WITNESS
18A. SIGNATURE OF
WITNESS (Sign in ink. If adult child or parent or custodian/guardian
signed above using an "X")
