Form VA Form 21-0820 VA Form 21-0820 Report of General Information

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

REPORT OF GENERAL INFORMATION
1. VA OFFICE

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.

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

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

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

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

6A. TELEPHONE NUMBER OF VETERAN (Include Area Code)
DAY
EVENING
(

)

(

)

6B. E-MAIL ADDRESS (If applicable)
7. PERSON CONTACTED

8. ADDRESS OF PERSON CONTACTED

9. TYPE OF CONTACT (Check)

PERSONAL

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

TELEPHONE

(

)

I identified myself as a VA employee who is authorized to receive information (38 CFR 3.217)
I verified the identity of the caller as being the veteran/beneficiary/claimant/fiduciary by obtaining the
following (place an "X" or check mark next to each applicable item)
Check
Check
Check
THE BENEFICIARY
THE VETERAN
(i.e., DIC, Death Pension, Ch. 35, or
( )
( )
( )
Apportionment)

ANOTHER CLAIMANT

Claim Number or SSN

Veteran’s Claim Number or SSN

Veteran’s Claim Number or SSN

Full Name
Branch of Service
Entry OR Release Service Dates

Veteran’s Full Name
Veteran’s Branch of Service

Veteran’s Full Name
Veteran’s Branch of Service

Beneficiary’s Full Name

Claimant’s Full Name

(mm/yyyy__________________________)

Beneficiary’s SSN

Claimant’s Address

For change of address/direct deposit, you
must also ask the following:
Address of Record
Type of Benefit (Claimed or in receipt of)

For change of address/direct deposit, you
must also ask the following:
Address of Record
Type of Benefit (Claimed or in receipt of)

Current Check Amount

Current Check Amount

If dependents are of record:
Name and SSN or Spouse OR

If dependents are of record:
Name and SSN or Spouse OR

Name and birthday of one child

Name and birthday of one child

BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN:

Notification of Action
I read the following summary of the Privacy Act statement to the caller:
"I am a VA employee who is authorized to receive or request evidentiary information or statements that may result in a change in your VA
benefits. The primary purpose for gathering this information or statement is to make an eligibility determination. It is subject to verification
through computer matching programs with other agencies."
I informed caller we will issue a notification letter incorporating this information.
I informed caller that information provided would be used to calculate benefit amounts that may result in a reduction or termination.
I informed caller that any potential overpayment could be reduced by immediate action.
I confirmed the caller understood and that he or she elected immediate action to minimize a potential debt.
cc to POA (If applicable):
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, 58VA/21/22/28 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 information on where to send comments or suggestions about this form.

VA FORM
NOV 2008

21-0820