VA Form 21-22

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 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 an individual assist you with your claim instead of a VSO, complete VA Form 21-22a, Appointment of Individual

as Claimant's Representative. For more information, you can contact us through Ask VA: https://ask.va.gov/, or call us toll-free

at 1-800-827-1000 (TTY:711). VA forms are available at www.va.gov/vaforms. After completing the form, use the mailing

addresses provided on Page 4.

SECTION III: SERVICE ORGANIZATION INFORMATION

SECTION II: CLAIMANT'S INFORMATION (If other than veteran)

SECTION I: VETERAN'S INFORMATION

11B. RELATIONSHIP TO VETERAN

APPOINTMENT OF VETERANS SERVICE ORGANIZATION AS

CLAIMANT'S REPRESENTATIVE

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.

SUPERSEDES VA FORM 21-22, FEB 2019

OMB Control No. 2900-0321

Respondent Burden: 5 minutes

Expiration Date:7/31/2026

VA FORM

JUL 2023

21-22

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

1. VETERAN'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER (SSN)

4. VETERAN'S DATE OF BIRTH

(MM/DD/YYYY)

6. INSURANCE NUMBER(S)

(If applicable) (Include letter prefix)

3. VA FILE NUMBER (If applicable)

13.TELEPHONE NUMBER (Include Area Code)

YearDayMonth

5. VETERAN'S SERVICE NUMBER (If applicable)

10. CLAIMANT'S NAME (First, Middle Initial, Last)

12. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number City

ZIP Code/Postal CodeState/Province Country

14. EMAIL ADDRESS (Optional)

8. TELEPHONE NUMBER (Include Area Code) 9. EMAIL ADDRESS (Optional)

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)

Page 1

7. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number City

ZIP Code/Postal CodeState/Province Country

INSTRUCTIONS:

NOTE:

11A. CLAIMANT'S DATE OF BIRTH

YearDayMonth

SECTION V: SIGNATURES

SECTION IV: AUTHORIZATION INFORMATION

VA USE

ONLY

NOTE: THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC

VA FORM 21-22, JUL 2023

COPY OF VA FORM 21-22 SENT TO:

REVOKED

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

ACKNOWLEDGED (Date)

(MM/DD/YYYY)

DATE SENT

(MM/DD/YYYY)

VR&E FILE EDU FILE

LG FILE INSURANCE FILE

VETERAN'S SOCIAL SECURITY NUMBER

Page 2

20. LIMITATION OF CONSENT- I authorize disclosure of records related to treatment for all conditions listed in Item 19 except:

DRUG ABUSE

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.

ALCOHOLISM OR ALCOHOL ABUSE

INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)

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

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, 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.

22A. SIGNATURE OF VETERAN OR CLAIMANT (Required) 22B. DATE SIGNED (MM/DD/YYYY)

23A. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 16A (Required) 23B. DATE SIGNED (MM/DD/YYYY)

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.

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.

NOTE:

PENALTY:

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

American Veterans (AMVETS)

Armed Forces Services Corporation

Army and Navy Union, USA

Blinded Veterans Association

Catholic War Veterans of the U.S.A.

Dale K. Graham Veterans Foundation

Disabled American Veterans

Fleet Reserve Association

Gold Star Wives of America, Inc.

Green Beret Foundation

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 Association of County Veterans Service Officers, Inc,

National Law School Veterans Clinic Consortium

National Association for Black Veterans, Inc.

National Veterans Legal Services Program

National Veterans Organization of America

Navajo Nation Veterans Administration

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

United Spanish War Veterans of the United States

United Spinal Association, Inc.

Veterans of Foreign Wars

Veterans of World War I of the U.S.A., Inc.

Veterans' Voice of America

Vietnam Veterans of America

Veterans of the Vietnam War, Inc. & The Veterans Coalition

Wounded Warrior Project

National Montford Point Marine Association, Inc.

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

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

WyomingMassachusetts

Maryland

Maine

Louisiana

Kentucky

Kansas

Iowa

Illinois

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 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 Veteran Readiness 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.

Page 3

VA FORM 21-22, JUL 2023

PRIVACY ACT NOTICE:

RESPONDENT BURDEN:

COMPENSATION CLAIMS PENSION & SURVIVORS BENEFIT CLAIMS

FIDUCIARY BOARD OF VETERANS' APPEALS

WHERE TO SEND YOUR WRITTEN CORRESPONDENCE

Page 4

VA FORM 21-22, JUL 2023

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.

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

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.