Form VA Form 21-0845 VA Form 21-0845 Authorization to Disclose Personal Beneficiary/Claimant

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO
DISCLOSE PERSONAL BENEFICIARY/CLAIMANT INFORMATION TO A THIRD PARTY
GENERAL INFORMATION
At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept
confidential. In accordance with section 41of the Freedom of Information and Protection of Privacy Act,
VA will only use the information in its custody or control in the following circumstances: where the
individual identifies the particular information and consents to its use; for the purpose for which it was
collected or a consistent purpose (i.e. a purpose which the individual might have reasonably expected).
By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit
information for any purpose that isn’t contained in VA’s System of Records, 58VA21/22/28
Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA. You
may revoke your written permission at any time, except if VA has already acted based on your
permission.

SPECIFIC INSTRUCTIONS
ITEMS 1 THROUGH 5 - In this section, give us the pertinent contact information to include name,
address, contact numbers, and e-mail address.
ITEM 6- Tell us the type of information you would like VA to release to your authorized third party.
ITEMS 7& 8- This section tells VA the terms of releasing your information. Tell us when to stop releasing
your personal benefit or claim information to your authorized third party. Check the box that applies and
fill in dates, if applicable.
ITEMS 9A & 9B - VA will give your personal benefit or claim information to the person(s) or
organization(s) you fill in here. You may fill in more than one person or organization. If you
designate an organization, you must also identify one or more individuals in that organization to whom
VA may disclose your benefit or claim information. This form cannot be used to disclose federal tax
information to third parties.
ITEMS 10A & 10B - Select the security question you would like us to ask your designated third party and
provide the answer. This question will be asked each time your designated third party contacts our office.

WHERE DO I SEND MY COMPLETED FORM?
You can obtain the VA mailing address to send your completed, signed authorization by calling toll-free
1-800-827-1000 (Hearing Impaired 1-800-829-4833). You can also locate the address of the closest VA
regional office on the Internet at http://www.va.gov/directory or in the government pages of your
telephone book under "United States Government, Veterans."
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want VA to give out your personal benefit or claim information, write
us a letter to revoke your authorization or complete Items 11A and 11B of the form. VA will no longer
give benefit information (except for the information VA has already given out based on your permission).

VA FORM
APR 2009

21-0845

OMB Approved No. 2900-XXXX
Respondent Burden: 5 minutes
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

AUTHORIZATION TO DISCLOSE PERSONAL BENEFICIARY/CLAIMANT
INFORMATION TO A THIRD PARTY
INSTRUCTIONS: Use this form if you want to give the Department of Veterans Affairs permission
to release your personal beneficiary or claim information to a third party.
1. FIRST, MIDDLE, LAST NAME OF VETERAN (Print clearly)

2. FIRST, MIDDLE, LAST NAME OF CLAIMANT WHO IS NOT THE VETERAN (Print clearly)

3. VA FILE NUMBER

4. SOCIAL SECURITY NUMBER

5. CONTACT INFORMATION
A. DAYTIME PHONE NUMBER

B. CELL PHONE NUMBER

C. E - MAIL ADDRESS (If applicable)

6. I (beneficiary/claimant) authorize the Department of Veterans Affairs (VA) to contact the persons or organizations listed below for the purposes
of providing the following information pertaining to my VA record. Check only one box below to tell VA the specific benefit or claim information
you want disclosed.
Any Information (Skip to Item 8)

Limited Information (Go to Item 7)

7. IF YOU SELECTED "LIMITED INFORMATION", CHECK ALL THAT APPLY
Status of pending claim or appeal

Account receivable balance

Other
_________________________________

Current benefit and rate

Request a benefit payment letter

_________________________________

Payment history

Change of address or direct deposit

8. IF YOU SELECTED "ANY INFORMATION", THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE:
From the date of signing below until _______________________________________
One time only
(Specify date - month, day, year)

Ongoing until written notice is given to VA to terminate or revoked in Items 11A & 11B
9. VA IS AUTHORIZED TO DISCLOSE INFORMATION AS SPECIFIED IN ITEMS 7 AND 8 TO THE PERSON(S) OR ORGANIZATION(S) LISTED BELOW. NOTE: IF
AUTHORIZATION IS FOR AN ORGANIZATION, PLEASE PROVIDE THE FIRST AND LAST NAME OF THE ORGANIZATIONS REPRESENTATIVE. (Please print clearly).
A. NAME OF PERSON OR ORGANIZATION

B. ADDRESS OF PERSON OR ORGANIZATION

10. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY
QUESTION BOX IN 10A AND PROVIDE THE ANSWER IN 10B.
A. SECURITY QUESTION

B. ANSWER

The city and state your mother was born in
The name of the high school you attended
Your first pet’s name
Your favorite teacher’s name
Your father’s middle name
11A. IF YOU WANT THIS AUTHORIZATION TO BE REVOKED PROVIDE THE REASON BELOW AND DATE IN 11B

11B. DATE REVOKED

12A. SIGNATURE (Do NOT print)

12B. DATE SIGNED

PRIVACY ACT INFORMATION: 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, 58VA21/22/28 Compensation,
Pension, Education, and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. Your obligation to respond is voluntary. 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.
RESPONDENT BURDEN - We need this information to release your private benefit and/or claim information to a designated third party(ies). 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.