21-22 Appointment of Veterans Service Organization as Claimant

OMB Control No. 2900-0321
Respondent Burden: 5 minutes
Expiration Date: XXXXXXX

APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT'S REPRESENTATIVE

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

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. See Page 4 for information on how to submit the completed form, either by mail, in person at a VA regional office or
electronically. 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)

3. VA FILE NUMBER (If applicable)

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

Day

Year

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

5. VETERAN'S SERVICE NUMBER (If applicable)

7. VETERAN'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
Country

ZIP Code/Postal Code

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

9. VETERAN'S EMAIL ADDRESS (Optional)

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

11. 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
Country

ZIP Code/Postal Code

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

13. CLAIMANT'S EMAIL ADDRESS (Optional)

14. RELATIONSHIP TO VETERAN

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

16A. NAME OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE
ORGANIZATION NAMED IN ITEM 15 (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)

16B. JOB TITLE OF PERSON NAMED IN ITEM 16A

17. EMAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 15

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

VA FORM
XXX XXXX

21-22

SUPERSEDES VA FORM 21-22, FEB 2019

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION IV: AUTHORIZATION INFORMATION
19. 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 15 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 15, either by
explicit revocation or the appointment of another representative.
20. LIMITATION OF CONSENT- I authorize disclosure of records related to treatment for all conditions listed in Item 19 except:
DRUG ABUSE

INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)

ALCOHOLISM OR ALCOHOL ABUSE

SICKLE CELL ANEMIA

21. AUTHORIZATION TO CHANGE CLAIMANT'S ADDRESS - By checking the box below, I authorize the organization named in Item 15 to act on my
behalf to change my address in my VA records.

I authorize any official representative of the organization named in Item 15 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 16A is not my appointed fiduciary.
I, the claimant named in Items 1 or 10, hereby appoint the service organization named in Item 15 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 19 and 20), 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 20.6. 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
22A. SIGNATURE OF VETERAN OR CLAIMANT (Do Not Print)

22B. DATE SIGNED (MM/DD/YYYY)

23A. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 16A (Do Not Print)

23B. DATE SIGNED (MM/DD/YYYY)

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:

VA USE
ONLY

VR&E FILE

EDU FILE

LG FILE

INSURANCE FILE

DATE SENT

(MM/DD/YYYY)

ACKNOWLEDGED (Date)

REVOKED (Reason and date (MM/DD/YYYY))

(MM/DD/YYYY)

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)
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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WHERE TO SEND YOUR WRITTEN CORRESPONDENCE
Documents may be submitted by mail, in person at a VA regional office or electronically. However, VA recommends submitting
correspondence electronically as this is the fastest method of receipt.
VA provides several tools to assist in electronic submission. To learn more about how to submit documents and claims electronically,
visit www.va.gov/disability/upload-supporting-evidence. You can also go directly to access.va.gov to digitally upload any
correspondence using Direct Upload.
By visiting www.va.gov you can also check your claims status and learn about other VA benefits.
If you need assistance, you can find a local, accredited representative at https://www.benefits.va.gov/vso/.
If you prefer to mail your correspondence, please use the related mailing address below.
COMPENSATION CLAIMS

PENSION & SURVIVORS BENEFIT CLAIMS

Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365

FIDUCIARY

BOARD OF VETERANS' APPEALS

Department of Veterans Affairs
Fiduciary Intake
PO Box 95211
Lakeland, FL 33804-5211

Department of Veterans Affairs
Board of Veterans' Appeals
PO Box 27063
Washington, DC 20038

These addresses serve all United States and foreign locations.

VA FORM 21-22, XXX XXXX

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