VA Form 21-0820d Report of Non-Receipt of Payment

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

REPORT OF NON-RECEIPT OF PAYMENT
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. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

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

(

)

EVENING

(

)

CELL

(
8. PERSON WHO CONTACTED YOU

7. E-MAIL ADDRESS (If applicable)

)

9. TYPE OF CONTACT (Check)
PERSONAL
TELEPHONE
11. TELEPHONE NUMBER OF PERSON WHO CONTACTED
YOU (Include Area Code)

10. ADDRESS OF PERSON WHO CONTACTED YOU

(

)

12. I verified the identity of the caller as being the veteran/beneficiary/claimant/fiduciary by obtaining the following (place an "X" or check mark
employee who is authorized to receive information (38 CFR 3.217)
Check
(

Check

THE VETERAN

)

(

)

THE BENEFICIARY
(i.e., DIC, Death Pension, Ch. 35, or
Apportion

Check
(

ANOTHER CLAIMANT

)

Claim Number or SSN

Veteran’s Claim Number or SSN

Veteran’s Claim Number or SSN

Full Name

Veteran’s Full Name

Veteran’s Full Name

Branch of Service

Veteran’s Branch of Service

Veteran’s Branch of Service

Entry OR Release Service Dates

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:

For change of address/direct deposit, you
must also ask the following:

Address of Record

Address of Record

Type of Benefit (Claimed or in receipt of)

Type of Benefit (Claimed or in receipt of)

Current Check Amount
If dependents are of record:

Current Check Amount
If dependents are of record:

Name and SSN or Spouse OR

Name and SSN or Spouse OR

Name and birthday of one child

Name and birthday of one child

13. THE FOLLOWING STATEMENT WAS READ TO CALLER
If the original check is found or received, you must return the original check to the Treasury Department and await receipt of the replacement check. If both checks are
negotiated, then you will be responsible for the duplicate payment. You will receive a letter from the Debt Management Center with instructions concerning collection.
14. CADD WAS DONE
YES
NO
16. DATE OF MISSING PAYMENT

15. PAYMENT WAS ISSUED VIA
PAPERCHECK
17. TYPE OF PAYMENT
REGULAR

DIVISION OR SECTION

BDN

VETSNET
Amount of payment: $________________________
18. IF PAPER CHECK WAS THE CHECK STOLEN/ENDORSED?

RETRO
IRREGULAR
EXECUTED BY (Signature and Title)

YES

NO

TO BE COMPLETED BY FINANCE ONLY
RUPD INPUT DATE

REGIONAL OFFICE

SIGNATURE

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."
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-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 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

21-0820d