21-22a Appointment of Individual as Claimant's Representative

OMB Control No. 2900-0321
Respondent Burden: 5 Minutes
Expiration Date: XXXXXXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

APPOINTMENT OF INDIVIDUAL AS CLAIMANT'S REPRESENTATIVE
INSTRUCTIONS: Before completing the form, read the Privacy Act and Respondent Burden on Page 3. The VA Office of
General Counsel maintains a list of all attorneys, claims agents, and Veterans Service Organization (VSO) representatives
accredited by VA to assist veterans in preparing, presenting, and prosecuting claims for VA benefits at:
https://www.va.gov/ogc/apps/accreditation/index.asp. You can search this list by name, state, or zip code. We recommend you
use the list to confirm and validate VA accreditation before signing any contract or appointing someone to represent you on your
VA benefits claim. If you prefer to have a VSO assist you with your claim instead of an individual, complete, VA Form 21-22,
Appointment of Veterans Service Organization as Claimant's Representative. For more information, you can contact us
through Ask VA: https://ask.va.gov/, or call us toll-free at 800-827-1000 (TTY:711). VA forms are available at
www.va.gov/vaforms. After completing the form, use the mailing addresses provided on Page 3.

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 check box to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER (SSN)

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

3. VA FILE NUMBER (If applicable)

6. BRANCH OF SERVICE

5. SERVICE NUMBER (If applicable)

ARMY

NAVY

AIR FORCE

SPACE FORCE

NOAA

USPHS

MARINE CORPS

COAST GUARD

7. MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

8. TELEPHONE NUMBER (Include Area Code)

9. E-MAIL ADDRESS (Optional)

Enter International Phone Number
(If applicable)

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

12. RELATIONSHIP TO VETERAN

11. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY)

13. CLAIMANT'S MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
No. &
Street
Apt./Unit Number

City

State/Province

ZIP Code/Postal Code

Country

14. TELEPHONE NUMBER (Include Area Code)

15. EMAIL ADDRESS (Optional)

Enter International Phone Number
(If applicable)

SECTION III: APPOINTED REPRESENTATIVE'S INFORMATION
16A. NAME OF INDIVIDUAL APPOINTED AS REPRESENTATIVE (First, Middle Initial, Last)
16B. INDIVIDUAL IS (check appropriate box)
ATTORNEY

AGENT

INDIVIDUAL PROVIDING REPRESENTATION UNDER SECTION 14.630 (*See required statement below.
Signatures are required in Items 17A and 18A)

SERVICE ORGANIZATION REPRESENTATIVE(Specify
organization)

VA FORM
XXXX

21-22a

SUPERSEDES VA FORM 21-22a, FEB 2019

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VETERAN'S SOCIAL SECURITY NO.
16C. ADDRESS OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE (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

16D. TELEPHONE NUMBER OF INDIVIDUAL APPOINTED AS
CLAIMANT'S REPRESENTATIVE (Include Area Code)

16E. EMAIL ADDRESS OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE
(Optional)

Enter International Phone Number
(If applicable)

*INDIVIDUALS PROVIDING REPRESENTATION UNDER SECTION 14.630
(Skip to Item 19, if the box for "Individual Providing Representation Under Section 14.630" was not checked in Item 16B)
NOTE: An individual acting as representative under 38 C.F.R. 14.630 may not represent more than one claimant on a single claim unless an exception to that limitation has
been granted by the Department of Veterans Affairs' (VA) General Counsel.
The appointment of the individual named in Item 16A (the representative) authorizes that person to represent the individual named in Item 1 or 10(if other than veteran) is for a
particular claim pursuant to the provisions of 38 C.F.R. 14.630. By our signatures below, we, the representative and the claimant, attest that no compensation will be charged by
or paid for the individual named in Item 16A.
17A. SIGNATURE OF VETERAN NAMED IN ITEM 1 OR CLAIMANT IN ITEM 10 (Required only for representation 17B. DATE SIGNED (MM/DD/YYYY)
under 14.630)

18A. SIGNATURE OF REPRESENTATIVE NAMED IN ITEM 16A (Required only for representation under 14.630)

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

SECTION IV: AUTHORIZATION INFORMATION
19. AUTHORIZATION FOR DISCLOSURE TO AFFILIATED PERSONNEL
If the individual in Item 16A is an accredited agent or attorney who has been approved by VA for access to VA IT systems in accordance with 38
CFR 1.600 to 1.603, I authorize VA to disclose all of my records (other than as provided in Items 20 and 21) to the associate attorneys, claims
agents, and support staff approved by VA for access to VA IT systems and affiliated with my representative. Provide the name of the firm/
organization here:

If the individual in Item 16A is an accredited agent or attorney, I authorize VA to disclose all my records (other than as provided in Items 20 and 21)
to the following individuals named as administrative employees of my representative. This applies to disclosures, outside of those made via access
to VA electronic information technology systems contemplated by 38 CFR 1.600 to 1.603. Provide the names of the individuals here:

20. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38 U.S.C. Unless I check the box below, I
do not authorize VA to disclose to the individual named in Item 16A 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 sickly cell anemia.
I authorize the VA facility having custody of my VA claimant records to disclose to the individual named in Item 16A, and the firm/organization named in
Item 19 (if approved by VA for affiliated access) all treatment records relating to drug abuse, alcoholism or alcohol abuse, infection with the human
immunodeficiency virus (HIV), or sickle cell anemia. Redisclosure of 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 individual named in Item 16A,
either by explicit revocation or the appointment of another representative.
21. LIMITATION OF CONSENT. My consent in Item 20 for the disclosure of records relating to treatment for drug abuse, alcoholism or alcohol abuse, infection with
the human immunodeficiency virus (HIV), or sickle cell anemia is limited as follows:

VA Form 21-22a, XXXX

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VETERAN'S SOCIAL SECURITY NO.

22. AUTHORIZATION FOR REPRESENTATIVE TO ACT ON CLAIMANT'S BEHALF TO CHANGE CLAIMANT'S ADDRESS
Unless I check the box below, I do not authorize the individual named in Item 16A to act on my behalf to change my address in my VA records.
I authorize the individual named in Item 16A to act on my behalf to change my address in my VA records. This authorization does not extend to
any other individual 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 individual named in Item 16A, either by explicit
revocation or the appointment of another representative.

CONDITIONS OF APPOINTMENT

I, the veteran named in Item 1 or the claimant named in Item 10, hereby appoint the individual named in Item 16A as my representative to prepare,
present, and prosecute my claims for any and all benefits from VA based on the service of the veteran named in Item 1. If the individual named in Item
16A is an accredited agent or attorney, the scope of representation provided before VA may be limited by the agent or attorney as indicated below in
Item 24. I authorize VA to disclose any and all of my records (other than as provided in Items 20 and 21) to that individual appointed as my
representative and as indicated in Item 19.
Signed and accepted subject to the foregoing conditions.
23A. SIGNATURE OF VETERAN/CLAIMANT (Required)

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

24. LIMITATIONS ON REPRESENTATION - AGENTS OR ATTORNEYS ONLY (Unless limited by an agent or attorney, this power of attorney revokes all
previously existing powers of attorney)

25A. SIGNATURE OF REPRESENTATIVE (Required)

25B. DATE SIGNED (MM/DD/YYYY)

FEES: Section 5904, Title 38, United States Code, contains provisions regarding fees that may be charged, allowed, or paid for services of agents or
attorneys in connection with a proceeding before the Department of Veterans Affairs with respect to benefits under laws administered by the Department.
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.
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 prefer to mail your correspondence, please use the related mailing address below.

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

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

PENSION & SURVIVORS BENEFIT CLAIMS
Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365

BOARD OF VETERANS' APPEALS
Department of Veterans Affairs
Board of Veterans' Appeals
PO Box 27063
Washington, DC 20038

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, failure to respond provide the requested information could
impede the recognition of your representative and/or identification of disclosable records. Except for information protected by 38 U.S.C. 7332, your representative is not
prohibited from redisclosing records. 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 individuals appointed by claimants to act on their behalf in the preparation, presentation, and
prosecution of claims for VA benefits (38 U.S.C. 5902, 5903, and 5904) and for those individuals to accept appointment. We will also use the information to verify consent for
disclosure of VA records to the appointed representative (38 U.S.C. 5701(b) and 7332) Title 38, United States Code, allows us to ask for this information. We estimate that
claimants and individuals appointed for purposes of representation will each 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. A Valid OMB control number 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 21-22a, XXXX

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