Form VA Form 27-0820 VA Form 27-0820 Report of General Information

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

REPORT OF GENERAL INFORMATION
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.

1. VA OFFICE

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

4. DATE OF CONTACT (Month, day, year)

6A. TELEPHONE NUMBER OF VETERAN (Include Area Code)
DAY

EVENING

6B. E-MAIL ADDRESS (If applicable)
7. NAME OF PERSON CONTACTED

8. TYPE OF CONTACT

9. ADDRESS OF PERSON CONTACTED

10. TELEPHONE NUMBER OF PERSON CONTACTED

PERSONAL

TELEPHONE

(Include Area Code)

I certify that I properly identified my caller using the ID Protocol
11. BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN:

Notification of Action
I read the following statement to the caller:
"I am a VA employee who is authorized to receive or request evidentiary information or statements that may result in a change in your VA benefits. The
primary purpose for gathering this information or statement is to make an eligibility determination. It is subject to verification through computer matching
programs with other agencies."
cc: POA (If applicable):
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, 58VA/21/22/28 Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is 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 the 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

27-0820

SUPERSEDES VA FORM 27-0820, JUL 2018,
WHICH WILL NOT BE USED.