Form VA Form 21-4193 VA Form 21-4193 Notice to Department of Veterans Affairs of Veteran or B

OMB Approved No. 2900-0116
Respondent Burden: 15 minutes

NOTICE TO DEPARTMENT OF VETERANS AFFAIRS
OF VETERAN OR BENEFICIARY INCARCERATED
IN PENAL INSTITUTION

1. VA FILE NUMBER (If known)

NOTE: Pursuant to Title 38, U.S.C., sections 1505, 3482, 3680 and 5313, awards of Department of Veterans Affairs benefits for veterans and
beneficiaries are subject to adjustment or discontinuance while such persons are incarcerated.
ADDRESS OF VA REGIONAL OFFICE

NAME AND ADDRESS OF INSTITUTION

TO

FROM

PRIVACY ACT INFORMATION: 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, Compensation,
Pension, Education and Rehabilitation Records - VA, and published in the Federal Register. Your obligation to respond is voluntary. Information submitted is subject
to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine the adjustment or discontinuance of VA benefits for veterans and beneficiaries who are incarcerated.
Title 38, United States Code 1505, 3482, 3680, and 5313, 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.
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.whitehouse.gov/omb/library/OMBINV.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about
this form.
2. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

3A. SERVICE NUMBER

3B. SOCIAL SECURITY NO.

4. NAME OF PERSON INCARCERATED, IF OTHER THAN VETERAN

5. RELATIONSHIP TO VETERAN

6. DATE OFFENSE WAS COMMITTED

7. TYPE OF OFFENSE FOR WHICH COMMITTED

9. LENGTH OF SENTENCE

FELONY
MISDEMEANOR
10. SCHEDULED RELEASE DATE

11B. DATE ENTERED PROGRAM

3C. DATE OF BIRTH

8. DATE OF COMMITMENT FOLLOWING CONVICTION

11A. IS INDIVIDUAL IN A WORK RELEASE OR
HALFWAY HOUSE PROGRAM?

YES
NO
12. INSTITUTIONAL TELEPHONE NUMBER (Including Area Code)

13. REMARKS

14. DATE SIGNED

VA FORM
SEP 2005

21-4193

15. NAME AND TITLE OF INSTITUTIONAL OFFICIAL

SUPERSEDES VA FORM 21-4193, JUN 2004,
WHICH WILL NOT BE USED.

16. SIGNATURE OF INSTITUTIONAL OFFICIAL