VA Form 21-0820e Report of Incarceration

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

REPORT OF INCARCERATION
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 AND TITLE OF PERSON CONTACTED

6. TYPE OF CONTACT

7. NAME AND ADDRESS OF INSTITUTION OR FACILITY CONTACTED (Check appropriate box)

8. TELEPHONE NUMBER OF PERSON CONTACTED
(Include Area Code)

FEDERAL
STATE

(

)

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

I contacted the above-named penal institution to confirm and document the following information.
(Complete two or more)
VETERAN’S SOCIAL SECURITY NUMBER______________________________

DATE OF BIRTH_____________________________________

DEPARTMENT OF CORRECTIONS INMATE NUMBER ________________________________

DATE ISSUED ______________________________________

INCARCERATION DATE
(Month, day, year)

FELONY

MISDEMEANOR

DATE OF CONVICTION
(Month, day, year)

DATE OF
RELEASE
(Month, day, year)

TYPE OF
RELEASE

NO ACTION NECESSARY
10. ADDITIONAL REMARKS

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 to 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 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 information on where to send comments or suggestions about this form.

VA FORM
NOV 2008

21-0820e