VA Form 20-10208 Document/Evidence Submission

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

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

DOCUMENT EVIDENCE SUBMISSION
INSTRUCTIONS: Read the Privacy Act and Respondent Burden on Page 2 before completing this
form. This form is used for the submission of additional documentation or evidence in support of a
claim. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay
number is 711. VA forms are available at www.va.gov/vaforms.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable circle to help
expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM-DD-YYYY)

3. VA FILE NUMBER (If applicable)

5. CURRENT 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

7. E-MAIL ADDRESS

6. TELEPHONE NUMBER (Include Area Code)

I agree to receive electronic correspondence from VA in regards to my claim.

Enter International Phone Number
(If applicable)

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

9. SOCIAL SECURITY NUMBER

11. DATE OF BIRTH (MM-DD-YYYY)

10. VA FILE NUMBER (If applicable)

12. CURRENT 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

14. E-MAIL ADDRESS

13. TELEPHONE NUMBER (Include Area Code)

I agree to receive electronic correspondence from VA in regards to my claim.

Enter International Phone Number
(If applicable)

SECTION III: DOCUMENT/EVIDENCE TYPE YOU ARE SUBMITTING
15. IS THIS FORM BEING SUBMITTED IN RESPONSE TO A REQUEST YOU RECEIVED FROM VA?

YES
VA FORM
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20-10208

NO
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VETERAN/CLAIMANT'S SOCIAL SECURITY NO.

16. IDENTIFY THE DOCUMENT(S) OR EVIDENCE YOU ARE SUBMITTING TO SUPPORT YOUR ESTABLISHED CLAIM.
NOTE: You may select one or more type(s), depending on the type of documentation/evidence being provided with this form.

BIRTH CERTIFICATE

DEATH CERTIFICATE

DEPENDENCY INFORMATION

DIVORCE DECREE

FINANCIAL INFORMATION

MARRIAGE CERTIFICATE

MEDICAL TREATMENT RECORDS

COURT PAPERS/DOCUMENTS

MILITARY PERSONNEL RECORDS

SERVICE TREATMENT RECORDS

LAY STATEMENT (Describe)

OTHER (Describe)

SECTION IV: CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have filled this form out completely and that it is true and correct to the best of my knowledge and belief.
17A. VETERAN/CLAIMANT'S SIGNATURE (REQUIRED) (Note: During
COVID-19 ink and electronic signatures are accepted)

17B. DATE SIGNED (MM-DD-YYYY)

SECTION V: THIRD-PARTY SIGNATURE
(Valid only if requester has an authorized third-party)
I CERTIFY THAT the veteran/claimant has authorized me as the undersigned representative and certifies that the information contained in
this document is true and complete to the best of the veteran/claimant's knowledge. NOTE: A third-party signature will not be accepted
unless a valid VA Form 21-0845, Authorization to Disclose Personal Information to a Third-Party, is of record or attached to this request. A
third-party may be a family member or other designated person who is not a Power of Attorney, agent, or fiduciary.
18A.THIRD-PARTY SIGNATURE (Note: During COVID-19 ink and
electronic signatures are accepted)

18B. DATE SIGNED (MM-DD-YYYY)

SECTION VI: POWER OF ATTORNEY (POA) SIGNATURE
(Valid only if requester has an authorized POA representation)
I CERTIFY THAT the veteran/claimant has authorized me as the undersigned representative and certifies that the information contained in
this document is true and complete to the best of veteran/claimant's knowledge.
NOTE: A POA's signature will not be accepted unless a valid VA Form 21-22, Appointment of Veterans Service Organization as
Claimant's Representative, or VA Form 21-22a, Appointment of Individual as Claimant's Representative, is of record or attached to this
request.
19A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE (Note: During COVID-19
ink and electronic signatures are accepted)

19B. 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 to be false, or for fraudulent receipt of any document to which you are not entitled.
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.
RESPONDENT BURDEN: This information will let us help you in support of or response to your claim. 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
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20-10208

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