14. REMARKS
I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.
15. SIGNATURE
16. DATE SIGNED (MM/DD/YYYY)
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 is false, or fraudulent acceptance of any payment to which you are not entitled.
RESPONDENT BURDEN: We need this information in order to assist you in supporting your claim for post-traumatic stress disorder (38 U.S.C. 5107 (a)). Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour 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.
PRIVACY ACT NOTICE: 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 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. However, the requested information is
necessary to obtain supporting evidence of stressful incidents in service. If the information is not furnished completely or accurately, VA will not be able to thoroughly
research your military records for supporting evidence. The responses you submit are considered confidential (38 U.S.C. 5701).
SECTION III: VETERAN SIGNATURE
PAGE 3
VA FORM 21-0781, JUL 2017
VETERAN'S SOCIAL SECURITY NO.
NOTE: Information about persons who were killed or injured during the second incident (attach a separate sheet if more space is needed.)
SECTION II: STRESSFUL INCIDENTS (Continued)
12A. NAME OF PERSON (First, Middle Initial, Last)
12C. DATE OF INJURY/DEATH (MM/DD/YYYY)
12B. RANK (If applicable)
12D. PLEASE CHECK ONE
KILLED IN ACTION
KILLED NON-BATTLE
WOUNDED IN ACTION
INJURED NON-BATTLE
YearDayMonth
12E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
13A. NAME OF PERSON (First, Middle Initial, Last)
13C. DATE OF INJURY/DEATH (MM/DD/YYYY)
13B. RANK (If applicable)
13D. PLEASE CHECK ONE
KILLED IN ACTION
KILLED NON-BATTLE
WOUNDED IN ACTION
INJURED NON-BATTLE
YearDayMonth
13E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
OTHER
OTHER
