Form 21-0844 Certification of Fully Developed Claim

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

CERTIFICATION OF FULLY DEVELOPED CLAIM
Veterans’ Benefits Improvement Act of 2008
Public Law 110-389, Section 221(a)
VETERAN’S NAME

VA FILE NUMBER

CLAIMANT’S NAME (If other than the veteran)

CLAIMANT’S TELEPHONE NUMBER
DAY

CLAIMANT’S MAILING ADDRESS

EVENING

E-MAIL ADDRESS (If applicable)

Note: Please state the benefit that you are claiming and any associated disabilities below:
(Example - Service-connected disability compensation for my lower back, left knee and hearing loss).
THE FOLLOWING STATEMENT IS MADE IN CONNECTION WITH A CLAIM FOR BENEFITS:

As of the date below, I hereby certify that no additional information or evidence is available or needs to be submitted for
the claim to be adjudicated.
CLAIMANT’S SIGNATURE

DATE SIGNED

As of the date below, as a representative of the claimant, I hereby certify that no additional information or evidence is
available or needs to be submitted for my client’s claim to be adjudicated.
REPRESENTATIVE’S SIGNATURE

DATE SIGNED

PRIVACY ACT INFORMATION: 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 the VA system of records, Compensation, Pension, Education, Vocational Rehabilitation and
Employment Records - VA (58VA21/22/28), published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify
your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal
to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her 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. The requested information is considered relevant and necessary to
determine maximum benefits under the law. 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(s) 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 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.whitehouse.gov/omb/library/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
MAR 2009

21-0844