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pdfOMB Approved No. 2900-0659
Respondent Burden: 1 hour 10 minutes
Expiration Date: XXXXXXXX
VA DATE STAMP
DO NOT WRITE IN THIS SPACE
STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION
FOR POST-TRAUMATIC STRESS DISORDER (PTSD)
IMPORTANT: If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press
1, or visit https://www.veteranscrisisline.net/ to chat online, or send a text message to 838255 to receive
confidential support 24 hours a day, 7 days a week, 365 days a year. Support for deaf and hard of hearing
individuals is available.
INSTRUCTIONS: List the stressful incident or incidents that occurred in service that you feel contributed to your current
condition. For each incident, provide a description of what happened, the date, the geographic location, your unit assignment and
dates of assignment, and the full names and unit assignments of you know of who were killed or injured during the incident. Please
provide dates within at least a 60-day range and do not use nicknames. It is important that you complete the form in detail and be as
specific as possible so that research of military records can be thoroughly conducted. If more space is needed, attach a separate
sheet, indicating the item number to which the answers apply.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly and legibly to help process the form.
1. VETERAN/BENEFICARY NAME (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
4. DATE OF BIRTH (MM/DD/YYYY)
3. VA FILE NUMBER (If applicable)
Month
5. VETERAN'S SERVICE NUMBER (If applicable)
Day
Year
6. PREFERRED E-MAIL ADDRESS (Optional)
7A. PRIMARY TELEPHONE NUMBER (Include Area Code)
7B. SECONDARY TELEPHONE NUMBER (Include Area Code)
SECTION II: STRESSFUL INCIDENTS
8A. DATE FIRST INCIDENT OCCURRED (MM/DD/YYYY)
Month
Day
Year
8B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
FROM:
Month
Day
Year
TO:
Month
Day
Year
8C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
8D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
8E. DESCRIPTION OF THE INCIDENT
8F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT
VA FORM
XXXX
21-0781
SUPERSEDES VA FORM 21-0781, AUG 2014,
WHICH WILL NOT BE USED.
PAGE 1
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENTS (Continued)
NOTE: Information about persons who were killed or injured during the first incident (attach a separate sheet if more space is needed.)
9A. NAME OF PERSON (First, Middle Initial, Last)
9B. RANK (If applicable)
9C. DATE OF INJURY/DEATH (MM/DD/YYYY)
Month
Day
9D. PLEASE CHECK ONE
Year
KILLED IN ACTION
WOUNDED IN ACTION
KILLED NON-BATTLE
INJURED NON-BATTLE
OTHER
9E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
10A. NAME OF PERSON (First, Middle Initial, Last)
10B. RANK (If applicable) 10C. DATE OF INJURY/DEATH (MM/DD/YYYY) 10D. PLEASE CHECK ONE
Month
Day
Year
KILLED IN ACTION
WOUNDED IN ACTION
KILLED NON-BATTLE
INJURED NON-BATTLE
OTHER
10E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
11A. DATE SECOND INCIDENT OCCURRED (MM,DD,YYYY)
Month
Day
Year
FROM: Month
11B. DATES OF UNIT ASSIGNMENT (MM/DD/YYYY)
Day
Year
TO:
Month
Day
Year
11C. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)
11D. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
11E. DESCRIPTION OF THE INCIDENT
11F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT
VA FORM 21-0781, XXXX
PAGE 2
VETERAN'S SOCIAL SECURITY NO.
SECTION II: STRESSFUL INCIDENTS (Continued)
NOTE: Information about persons who were killed or injured during the first incident (attach a separate sheet if more space is needed.)
12A. NAME OF PERSON (First, Middle Initial, Last)
12B. RANK (If applicable) 12C. DATE OF INJURY/DEATH (MM/DD/YYYY)
Month
Day
Year
12D. PLEASE CHECK ONE
KILLED IN ACTION
WOUNDED IN ACTION
KILLED NON-BATTLE
INJURED NON-BATTLE
OTHER
12E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
13A. NAME OF PERSON (First, Middle Initial, Last)
13B. RANK (If applicable) 13C. DATE OF INJURY/DEATH (MM/DD/YYYY) 13D. PLEASE CHECK ONE
Month
Day
Year
KILLED IN ACTION
WOUNDED IN ACTION
KILLED NON-BATTLE
INJURED NON-BATTLE
OTHER
13E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,CAVALRY, SHIP)
14. REMARKS
SECTION III: VETERAN SIGNATURE
I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.
15. SIGNATURE
16. DATE SIGNED (MM/DD/YYYY)
PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact,
knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
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 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 VA system of records, 58VA21/22/28, Compensation, Pension, Education and
Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, the requested information is
necessary to obtain supporting evidence of stressful incidents in service. If the information is not furnished completely or accurately, VA will not be able to thoroughly
research your military records for supporting evidence. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information in order to assist you in supporting your claim for post-traumatic stress disorder (38 U.S.C. 5107 (a)). Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour 10 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.reginfo.gov/public/do/PRAMain. If
desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-0781, XXXX
PAGE 3
| File Type | application/pdf |
| File Title | 21-0781 |
| Subject | STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR POST-TRAUMATIC STRESS DISORDER (PTSD) |
| File Modified | 2017-03-09 |
| File Created | 2017-01-03 |