Form VA Form 21-22 VA Form 21-22 Appointment of Veterans Service Organization as Claimant

OMB Control No. 2900-0321
Respondent Burden: 5 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE
IMPORTANT: Please read the Privacy Act and Respondent Burden Information on Page 3
before completing the form.
NOTE: If you prefer to have an individual assist you with your claim instead of a veterans service organization please complete
VA Form 21-22a, Appointment of Individual as Claimant's Representative. When completed you can mail or fax this form to
the appropriate intake center address shown on Page 4. VA forms are available at www.va.gov/vaforms.
SECTION I: VETERAN'S INFORMATION
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER (SSN)

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

3. VA FILE NUMBER

Month

5. VETERAN'S SERVICE NUMBER (If applicable)

6. INSURANCE NUMBER(S) (If applicable) (Include letter prefix)

7. VETERAN'S TELEPHONE NUMBER (Include Area Code)

8. VETERAN'S EMAIL ADDRESS (Optional)

Day

Year

SECTION II: CLAIMANT'S INFORMATION (If other than veteran)
9. CLAIMANT'S NAME (First, Middle Initial, Last)

10. CLAIMANT'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

State/Province

City

ZIP Code/Postal Code

Country

11. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)

12. CLAIMANT'S EMAIL ADDRESS (Optional)

13. RELATIONSHIP TO VETERAN

SECTION III: SERVICE ORGANIZATION INFORMATION
14. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on Page 3 before selecting
organization)

15A. NAME OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE
ORGANIZATION NAMED IN ITEM 14 (This is an appointment of the entire organization
and does not indicate the designation of only this specific individual to act on behalf of the
organization)

15B. JOB TITLE OF PERSON NAMED IN ITEM 15A

16. EMAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 14

17. DATE OF THIS APPOINTMENT (MM/DD/YYYY)

VA FORM
XXX XXXX

21-22

SUPERSEDES VA FORM 21-22, AUG 2015,
WHICH WILL NOT BE USED.

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION IV: AUTHORIZATION INFORMATION
18. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C. - By checking the
box below I authorize VA to disclose to the service organization named on this appointment form any records that may be in my file relating to
treatment for drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia.

I authorize the VA facility having custody of my VA claimant records to disclose to the service organization named in
Item 14 all treatment records relating to drug abuse, alcoholism or alcohol abuse, infection with the human
immunodeficiency virus (HIV), or sickle cell anemia. Redisclosure of these records by my service organization
representative, other than to VA or the Court of Appeals for Veterans Claims, is not authorized without my further written
consent. This authorization will remain in effect until the earlier of the following events: (1) I revoke this authorization by
filing a written revocation with VA; or (2) I revoke the appointment of the service organization named in Item 14, either by
explicit revocation or the appointment of another representative.
19. LIMITATION OF CONSENT- I authorize disclosure of records related to treatment for all conditions listed in Item 18 except:
DRUG ABUSE

INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)

ALCOHOLISM OR ALCOHOL ABUSE

SICKLE CELL ANEMIA

20. AUTHORIZATION TO CHANGE CLAIMANT'S ADDRESS - By checking the box below, I authorize the organization named in Item 14 to
act on my behalf to change my address in my VA records.

I authorize any official representative of the organization named in Item 14 to act on my behalf to change my address in
my VA records. This authorization does not extend to any other organization without my further written consent. This
authorization will remain in effect until the earlier of the following events: (1) I file a written revocation with VA; or (2) I
appoint another representative, or (3) I have been determined unable to manage my financial affairs and the individual or
organization named in Item 15A is not my appointed fiduciary.
I, the claimant named in Items 1 or 9, hereby appoint the service organization named in Item 14 as my representative to prepare,
present and prosecute my claim(s) for any and all benefits from the Department of Veterans Affairs (VA) based on the service of
the veteran named in Item 1. I authorize VA to release any and all of my records, to include disclosure of my Federal tax
information (other than as provided in Items 18 and 19), to my appointed service organization. I understand that my appointed
representative will not charge any fee or compensation for service rendered pursuant to this appointment. I understand that the
service organization I have appointed as my representative may revoke this appointment at any time, subject to 38 CFR 20.608.
Additionally, in some cases a veteran's income is developed because a match with the Internal Revenue Service necessitated
income verification. In such cases, the assignment of the service organization as the veteran's representative is valid for only
five years from the date the claimant signs this form for purposes restricted to the verification match. Signed and accepted
subject to the foregoing conditions.
SECTION V: SIGNATURES
NOTE: THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
21A. SIGNATURE OF VETERAN OR CLAIMANT (Do Not Print)

21B. DATE SIGNED

22A. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 15A
(Do Not Print)

22B. DATE SIGNED

NOTE: As long as this appointment is in effect, the organization named herein will be recognized as the sole representative for
preparation, presentation and prosecution of your claim before the Department of Veterans Affairs in connection with your claim or
any portion thereof.
COPY OF VA FORM 21-22 SENT TO:
VR&E FILE

VA USE
ONLY

LG FILE

DATE SENT

ACKNOWLEDGED
(Date)

REVOKED (Reason and date)

EDU FILE

INSURANCE FILE

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material fact, knowing it
to be false or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-22, XXX XXXX

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RECOGNIZED SERVICE ORGANIZATIONS
Membership in an organization is not a prerequisite to appointment of the organization as claimant's representative.
The following is a listing of national, regional, or local organizations recognized by the Secretary of Veterans Affairs in the
preparation, presentation, and prosecution of claims under laws administered by the Department of Veterans Affairs.
African American PTSD Association
American Legion
American Red Cross
AMVETS
American Ex-Prisoners of War, Inc.
American GI Forum, National Veterans Outreach Program
Armed Forces Services Corporation
Army and Navy Union, USA
Associates of Vietnam Veterans of America
Blinded Veterans Association
Catholic War Veterans of the U.S.A.
Disabled American Veterans
Fleet Reserve Association
Gold Star Wives of America, Inc.
Italian American War Veterans of the United States, Inc.
Jewish War Veterans of the United States
Legion of Valor of the United States of America, Inc.
Marine Corps League
Military Officers Association of America (MOAA)
Military Order of the Purple Heart
National Amputation Foundation, Inc.

National Association of County Veterans Service Officers, Inc,
National Association for Black Veterans, Inc.
National Veterans Legal Services Program
National Veterans Organization of America
Navy Mutual Aid Association
Paralyzed Veterans of America, Inc.
Polish Legion of American Veterans, U.S.A.
Swords to Plowshares, Veterans Rights Organization, Inc.
The Retired Enlisted Association
The Veterans Assistance Foundation, Inc.
The Veterans of the Vietnam War, Inc. & The Veterans
Coalition
United Spanish War Veterans of the United States
United Spinal Association, Inc.
Veterans of Foreign Wars of the United States
Veterans of World War I of the U.S.A., Inc.
Vietnam Era Veterans Association
Vietnam Veterans of America
West Virginia Department of Veterans Assistance
Wounded Warrior Project

Although agency titles vary, the following States and possessions maintain veterans service agencies which are recognized to present
claims:
Alabama
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam

Hawaii
Idaho
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan

Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina

North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota

Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming

PRIVACY ACT NOTICE: 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, published in the Federal Register. Your obligation to respond is
voluntary. However, the requested information is considered relevant and necessary to recognize a service organization as your representative and/or identify
disclosable records. 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. 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. 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 recognize the service organization you name to act on your behalf in the preparation, presentation, and
prosecution of claims for VA benefits (38 U.S.C. 5902). We will also use the information to identify any VA records that we may disclose to the service
organization (38 U.S.C. 5701(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
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 21-22, XXX XXXX

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FOR ALL COMPENSATION CLAIMS MAIL OR FAX THIS FORM TO THE FOLLOWING ADDRESS:

Mail your form to:
Department of Veterans Affairs
Claims Intake Center
P.O. Box 4444
Janesville, WI 53547- 4444
Or fax your form to:
Toll Free: (844) 531- 7818
Local: 248-524-4260
FOR VETERANS PENSION AND SURVIVOR BENEFIT CLAIMS MAIL OR FAX THIS FORM TO THE APPROPRIATE
ADDRESS BELOW:

Mail your form to:
Department of Veterans Affairs
Claims Intake Center
Attn: Milwaukee Pension Center
P.O. Box 5192
Janesville, WI 53547-5192
Or fax your form to:
Toll Free: (844) 655-1604

Mail your form to:
Department of Veterans Affairs
Claims Intake Center
Attn: St. Paul Pension Center
P.O. Box 5365
Janesville, WI 53547-5365
Or fax your form to:
Toll Free: (844) 655-1604

This Pension Center Serves The Following:

Alabama

Arkansas

Illinois

Indiana

Kentucky

Louisiana

Michigan

Mississippi

Missouri

Ohio

Tennessee

Wisconsin

Mail your form to:
Department of Veterans Affairs
Claims Intake Center
Attn: Philadelphia Pension Center
P.O. Box 5206
Janesville, WI 53547-5206
Or fax your form to:
Toll Free: (844) 655-1604

This Pension Center Serves The Following:

Alaska

Arizona

California

Colorado

Hawaii

Idaho

Iowa

Kansas

Minnesota

Montana

Nebraska

Nevada

New
Mexico
South
Dakota

North
Dakota

Oklahoma

Oregon

Texas

Utah

Washington

Wyoming

Mexico

Central
America

South
America

Caribbean

This Pension Center Serves The Following:

Connecticut

Delaware

Florida

Georgia

Maine

Maryland

Massachusetts

New Jersey

New York

Pennsylvania

Rhode
Island
West
Virginia

South
Carolina
District of
Columbia

North
Carolina

New
Hampshire

Vermont

Virginia

Puerto Rico

Canada

Countries outside of North, Central or South America

VA Form 21-22, XXX XXXX

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