Form VA Form 21-10210 VA Form 21-10210 Lay/Witness Statement

OMB Approved No. 2900-0881
Respondent Burden: 10 Minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

LAY/WITNESS STATEMENT
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use this form to
submit a statement as a veteran/claimant or someone writing on your behalf to support a claim. If you or someone else
writing on your behalf are providing additional statement(s) to support your claim(s) please submit this form with your
application. 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. After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center,
P.O. Box 4444, Janesville, WI, 53547-4444.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, 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

3. VA FILE NUMBER (If applicable)

4. DATE OF BIRTH

5. VA INSURANCE FILE NUMBER (If applicable)
Year

Day

Month

6. CURRENT MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City
ZIP Code/Postal Code

Country

State/Province

7. TELEPHONE NUMBER (Include Area Code)

8. E-MAIL ADDRESS

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
(Complete this section ONLY IF the claimant is NOT the veteran)
9. CLAIMANT'S NAME (First, Middle Initial, Last)

11. VA FILE NUMBER (If applicable)

10. SOCIAL SECURITY NUMBER

12. DATE OF BIRTH
Month

13. VA INSURANCE FILE NUMBER (If applicable)

Day

Year

14. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
State/Province

Country

15. TELEPHONE NUMBER (Include Area Code)

ZIP Code/Postal Code
16. E-MAIL ADDRESS

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

Enter International Phone Number
(If applicable)
VA FORM
XXX XXXX

21-10210

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SOCIAL SECURITY NUMBER

SECTION III: STATEMENT
(Use this section to submit your statement, or a statement from someone else writing on your behalf)

NOTE: Please indicate the claimed issue that you are addressing. If you would like to submit an additional statement on your own behalf or if you have
more than one witness writing on your behalf, use a separate form (VA Form 21-10210) for each statement.
17. STATEMENT (Note: Describe what you yourself know or have observed about the facts or circumstances relevant to this claim before VA)

VA Form 21-10210, XXX XXXX

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SOCIAL SECURITY NUMBER

SECTION III: STATEMENT (Continued)
(Use this section to submit your statement, or a statement from someone else writing on your behalf)
17. STATEMENT (Note: Describe what you yourself know or have observed about the facts or circumstances relevant to this claim before VA)

SECTION IV: WITNESS CONTACT INFORMATION
(Complete Section IV and V if the statement in Section III is from someone else writing on your behalf)
18. WITNESS NAME (First, Middle Initial, Last)

19. RELATIONSHIP TO VETERAN/CLAIMANT (Check all that apply)
SERVED WITH VETERAN/CLAIMANT

FAMILY/FRIEND OF VETERAN/CLAIMANT

COWORKER/SUPERVISOR OF VETERAN/CLAIMANT

OTHER (Specify)
20. TELEPHONE NUMBER (Include Area Code)

21. E-MAIL ADDRESS

Enter International Phone Number
(If applicable)

SECTION V: CERTIFICATION OF STATEMENT AND SIGNATURE
I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.
22A. VETERAN/CLAIMANT/WITNESS SIGNATURE (REQUIRED)

22B. DATE SIGNED
Month

Day

Year

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, Vocational Rehabilitation and Employment Records - VA, published
in the Federal Register. Your obligation to respond is voluntary.
RESPONDENT BURDEN: This form is used to submit a statement that supports a claim already pending or already established with VA. Title 38, United States Code, allows us to ask for
this information. We estimate that you will need an average of 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 21-10210, XXX XXXX

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