VA Form 27-0820e Report of Incarceration

OMB Approved No. 2900-0734
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX

REPORT OF INCARCERATION
1. VA OFFICE
NOTE - This form must be filled out in ink or on a typewriter or
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. NAME AND TITLE OF PERSON CONTACTED

6. TYPE OF CONTACT
PERSONAL

7. NAME AND ADDRESS OF INSTITUTION OR FACILITY CONTACTED (Check appropriate box)
FEDERAL

STATE

TELEPHONE

8. TELEPHONE NUMBER OF PERSON CONTACTED

(Include Area Code)

9. BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (If needed, continue on a separate sheet)
I contacted the above-named penal institution to confirm and document the following information.

(Complete two or more)
VETERAN'S SOCIAL SECURITY NUMBER

DATE OF BIRTH

DEPARTMENT OF CORRECTIONS INMATE NUMBER
DATE OF CONVICTION

(Month, day, year)

FELONY

NO ACTION NECESSARY

MISDEMEANOR

DATE OF CONFINEMENT
AFTER CONVICTION

(Month, day, year)

DATE OF
RELEASE

(Month, day, year)

TYPE OF RELEASE

FURTHER ACTION NEEDED

10. ADDITIONAL REMARKS

A copy of this form was sent to Power of Attorney of record (If applicable)
cc:
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, 58VA21/22/28 Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond to 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 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.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
XXX XXXX

27-0820e

SUPERSEDES VA FORM 27-0820e, SEP 2015,
WHICH WILL NOT BE USED.