Form VA Form FL21-30 VA Form FL21-30 Request for Contact Information

DEPARTMENT OF VETERANS AFFAIRS

Enter VARO address

•

Enter recipient's name and address

In Reply Refer To:
File number:
Veteran:
Beneficiaries:

A representative from our office will contact you in the near future.
To assist us in arranging this meeting, please complete the form on the reverse side of this letter
and return it in the enclosed envelope.
VA now uses a centralized mail system. If you choose to respond in writing, please put your full
name and VA file number on each page. Send your application and any evidence in support of
your claim to the following address:
Department of Veterans Affairs
Evidence Intake Center
P. O. Box 4444
Janesville, WI 53547-4444
You can also provide the information by calling the VA, at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the federal number is 711.

Sincerely yours,

Enclosure

FL 21-30
XXX XXXX (RS)

OMB Approved No. 2900-0660
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

REQUEST FOR CONTACT INFORMATION
INSTRUCTIONS: Print all answers clearly. You must sign and date this form (Items
13 and 14). When you have completed this form, return it in the enclosed envelope to the
address in the letter on Page 1.
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'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)
Month

5. GENDER

MALE

Day

Year

6. TELEPHONE NUMBER (Include Area Code)

FEMALE
8. E-MAIL ADDRESS (Optional)

7. VETERAN'S SERVICE NUMBER (If applicable)

9. 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
Country

ZIP Code/Postal Code

SECTION II: MEETING LOCATION

NOTE: If you will be at home during the day, complete items 10A through 10B.
10A. HOME ADDRESS (If different from the one on the first page.) (If you serve as payee for a VA beneficiary, please provide that person's
address if different than your own.)

10B. DIRECTIONS TO YOUR HOME (If living in a RURAL AREA, give directions from nearest town and include directions, i.e., north,
south, etc., and highway names and numbers, mileage, and landmarks. If living in a town or city, give directions from a main intersection, a
conspicuous landmark, etc. Please draw a map if it will be helpful.)

NOTE: If you will NOT be at home during the day, complete item 11A.
11A. BUSINESS, FIRM OR OTHER NAME AND ADDRESS WHERE YOU CAN BE CONTACTED (Include hours worked.)

FL 21-30, XXX XXXX (RS)

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION II: MEETING LOCATION (Continued)
12. REMARKS

SECTION III: VETERAN/BENEFICIARY 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.
13. SIGNATURE (REQUIRED)

14. 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 the 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 5, Code of
Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological ore 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 required to obtain or retain benefits. You must give us your and your dependents SSN account information. Applicants are required to
provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C. 5101 (c) (1). The 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. Information that you furnish may be utilized in computer
matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by
virtue of your participation in any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine continued eligibility for an additional allowance for your spouse and/or child(ren). 38 U.S.C. 1115, Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 15 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. Valid OMB control numbers can be located on the OMB Internet page at
www.reginfo.gov/public/do/PRAMain. If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
FL 21-30, XXX XXXX (RS)

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