VA Form 21-0820c Report of Defense Finance & Accounting Service (DFAS)

OMB Control No. 2900-XXXX
Respondent Burden: 5 minutes

REPORT OF DEFENSE FINANCE & ACCOUNTING SERVICE (DFAS)
NOTE - This form must be filled out in ink or on a typewriter/computer, as it becomes a permanent record in the veteran’s folder.
1. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

2. VA OFFICE

3. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

4. DATE OF CONTACT (Month, day, year)

5. NAME OF PERSON YOU CONTACTED

6. TELEPHONE NUMBER OF PERSON WHO CONTACTED YOU (Include Area Code)

7. BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (If needed, continue on a separate sheet)

The following is information received from DFAS regarding the above-named veteran’s military retired pay and will be used to offset any
compensation award as provided by 38 CFR 3.750 and M21-1MR, Part III, Subpart V, Chapter 5.
The veteran’s record was properly identified by confirming the following information (check all that apply)
FULL NAME

DATE OF DEATH

PAY GRADE

SOCIAL SECURITY NUMBER

BRANCH OF SERVICE
DATES OF SERVICE

DATE OF BIRTH

8. SUMMARY OF INFORMATION RECEIVED:
In receipt?

YES

NO

PERMANENT

TDRL

SBP

9. RETIRED PAY/SBP/SEPARATION OR SEVERANCE PAY
A. Verified retired pay amount(s):

DATE ________________ GROSS PAY

B. Verified SBP:

DATE _________________________

AMOUNT _________________________

C. Verified Separation/Severance Pay

SEPARATION

SEVERANCE

DATE ________________ GROSS PAY
SBP OVERPAYMENT
DATE ________________ GROSS PAY

DATE __________________________

GROSS __________________________

NET_____________________________
DATE ________________ GROSS PAY

DATE ________________ GROSS PAY

A copy of this form was sent to Power of Attorney of record (If applicable)
cc:
DIVISION OR SECTION

EXECUTED BY (Signature and Title)

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 5, 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 Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. 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 5 minutes to respond to the questions on this form. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.whitehouse.gov/omb/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get the information on where to send comments or
suggestions about this form.
VA FORM
NOV 2008

21-0820c