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pdfOMB Control No. 2900-0321
Respondent Burden: 5 minutes
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT’S REPRESENTATIVE
Note - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, " Appointment of
Individual As Claimant’s Representative."
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.
1. LAST-FIRST-MIDDLE NAME OF VETERAN
2. VA FILE NUMBER (Include prefix)
3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)
3B. JOB TITLE OF OFFICIAL REPRESENTATIVE AUTHORIZED TO ACT ON VETERAN’S BEHALF
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
4. SOCIAL SECURITY NUMBER
5. INSURANCE NUMBER(S) (Include letter prefix)
6A. SERVICE NUMBER(S)
6B. BRANCH OF SERVICE
7. NAME OF CLAIMANT (If other than veteran)
8. RELATIONSHIP (If other than veteran)
9. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
10. CLAIMANT’S TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME
B. EVENING
(
)
(
)
11. E-MAIL ADDRESS (If applicable)
12. DATE OF THIS APPOINTMENT
13. 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 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 3A 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 above,
either by explicit revocation or the appointment of another representative.
14. LIMITATION OF CONSENT - My consent in Item 13 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:
I, the claimant named in Items 1 or 7, hereby appoint the service organization named in Item 3A as my representative to prepare,
present and prosecute my claim for any and all benefits from the Department of Veterans Affairs based on the service of the veteran
named in Item 1. I authorize the Department of Veterans Affairs to release any and all of my records, to include disclosure of my
Federal tax information (other than as provided in Items 13 and 14), to that service organization appointed as my representative. It is
understood that no fee or compensation of whatsoever nature will be charged me for service rendered pursuant to this power of
attorney. I understand that the service organization I have appointed as my representative may revoke this power of attorney at any
time, subject to 38 CFR 20.608. Additionally, in those cases where a veteran’s income is being developed because of an income
verification necessitated by an Internal Revenue Service verification match, the assignment of the service organization as the
veteran’s representative is only valid for five years from the date this form is signed for purposes restricted to the verification match.
Signed and accepted subject to the foregoing conditions.
THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
15. SIGNATURE OF CLAIMANT (Do Not Print)
16. DATE SIGNED
VA FORM 21-22-1 SENT TO:
DATE SENT
ACKNOWLEDGED
REVOKED (Reason and date)
VA
(Date)
CER
FILE
EDU
FILE
INSURANCE
USE
FILE
CH. 30
DEA FILE
LG FILE
ONLY
NOTE: As long as this appointment is in effect, the organization named herein will be recognized as the sole agent for presentation
of your claim before the Department of Veterans Affairs in connection with your claim or any portion thereof.
VA FORM
EXISTING STOCKS OF VA FORM 21-22, NOV 2005,
CLAIMS FOLDER 1
JUN 2009 21-22
WILL BE USED.
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 Organizations recognized by the Secretary in the preparation 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 Defenders of Bataan and Corregidor, Inc.
American GI Forum, National Veterans Outreach Program
Armed Forces Services Corporation
Army and Navy Union, USA
Blinded Veterans Association
Catholic War Veterans of the U.S.A.
Disabled American Veterans
Eastern Paralyzed Veterans Association
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 Order of the Purple Heart
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
Non Commissioned Officers Association of the USA
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
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
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
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
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
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 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA . If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.
OMB Control No. 2900-0321
Respondent Burden: 5 minutes
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT’S REPRESENTATIVE
Note - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, " Appointment of
Individual As Claimant’s Representative."
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.
1. LAST-FIRST-MIDDLE NAME OF VETERAN
2. VA FILE NUMBER (Include prefix)
3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)
3B. JOB TITLE OF OFFICIAL REPRESENTATIVE AUTHORIZED TO ACT ON VETERAN’S BEHALF
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
4. SOCIAL SECURITY NUMBER
5. INSURANCE NUMBER(S) (Include letter prefix)
6A. SERVICE NUMBER(S)
6B. BRANCH OF SERVICE
7. NAME OF CLAIMANT (If other than veteran)
8. RELATIONSHIP (If other than veteran)
9. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
10. CLAIMANT’S TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME
B. EVENING
(
)
(
)
11. E-MAIL ADDRESS (If applicable)
12. DATE OF THIS APPOINTMENT
13. 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 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 3A 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 above,
either by explicit revocation or the appointment of another representative.
14. LIMITATION OF CONSENT - My consent in Item 13 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:
I, the claimant named in Items 1 or 7, hereby appoint the service organization named in Item 3A as my representative to prepare,
present and prosecute my claim for any and all benefits from the Department of Veterans Affairs based on the service of the veteran
named in Item 1. I authorize the Department of Veterans Affairs to release any and all of my records, to include disclosure of my
Federal tax information (other than as provided in Items 13 and 14), to that service organization appointed as my representative. It is
understood that no fee or compensation of whatsoever nature will be charged me for service rendered pursuant to this power of
attorney. I understand that the service organization I have appointed as my representative may revoke this power of attorney at any
time, subject to 38 CFR 20.608. Additionally, in those cases where a veteran’s income is being developed because of an income
verification necessitated by an Internal Revenue Service verification match, the assignment of the service organization as the
veteran’s representative is only valid for five years from the date this form is signed for purposes restricted to the verification match.
Signed and accepted subject to the foregoing conditions.
THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
15. SIGNATURE OF CLAIMANT (Do Not Print)
16. DATE SIGNED
VA FORM 21-22-1 SENT TO:
DATE SENT
ACKNOWLEDGED
REVOKED (Reason and date)
VA
(Date)
CER
FILE
EDU
FILE
INSURANCE
USE
FILE
CH. 30
DEA FILE
LG FILE
ONLY
NOTE: As long as this appointment is in effect, the organization named herein will be recognized as the sole agent for presentation
of your claim before the Department of Veterans Affairs in connection with your claim or any portion thereof.
VA FORM
EXISTING STOCKS OF VA FORM 21-22, NOV 2005,
SERVICE ORGANIZATION 2
JUN 2009 21-22
WILL BE USED.
OMB Control No. 2900-0321
Respondent Burden: 5 minutes
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT’S REPRESENTATIVE
Note - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, " Appointment of
Individual As Claimant’s Representative."
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.
1. LAST-FIRST-MIDDLE NAME OF VETERAN
2. VA FILE NUMBER (Include prefix)
3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)
3B. JOB TITLE OF OFFICIAL REPRESENTATIVE AUTHORIZED TO ACT ON VETERAN’S BEHALF
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
4. SOCIAL SECURITY NUMBER
5. INSURANCE NUMBER(S) (Include letter prefix)
6A. SERVICE NUMBER(S)
6B. BRANCH OF SERVICE
7. NAME OF CLAIMANT (If other than veteran)
8. RELATIONSHIP (If other than veteran)
9. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
10. CLAIMANT’S TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME
B. EVENING
(
)
(
)
11. E-MAIL ADDRESS (If applicable)
12. DATE OF THIS APPOINTMENT
13. 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 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 3A 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 above,
either by explicit revocation or the appointment of another representative.
14. LIMITATION OF CONSENT - My consent in Item 13 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:
I, the claimant named in Items 1 or 7, hereby appoint the service organization named in Item 3A as my representative to prepare,
present and prosecute my claim for any and all benefits from the Department of Veterans Affairs based on the service of the veteran
named in Item 1. I authorize the Department of Veterans Affairs to release any and all of my records, to include disclosure of my
Federal tax information (other than as provided in Items 13 and 14), to that service organization appointed as my representative. It is
understood that no fee or compensation of whatsoever nature will be charged me for service rendered pursuant to this power of
attorney. I understand that the service organization I have appointed as my representative may revoke this power of attorney at any
time, subject to 38 CFR 20.608. Additionally, in those cases where a veteran’s income is being developed because of an income
verification necessitated by an Internal Revenue Service verification match, the assignment of the service organization as the
veteran’s representative is only valid for five years from the date this form is signed for purposes restricted to the verification match.
Signed and accepted subject to the foregoing conditions.
THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
15. SIGNATURE OF CLAIMANT (Do Not Print)
16. DATE SIGNED
VA FORM 21-22-1 SENT TO:
DATE SENT
ACKNOWLEDGED
REVOKED (Reason and date)
VA
(Date)
CER
FILE
EDU
FILE
INSURANCE
USE
FILE
CH. 30
DEA FILE
LG FILE
ONLY
NOTE: As long as this appointment is in effect, the organization named herein will be recognized as the sole agent for presentation
of your claim before the Department of Veterans Affairs in connection with your claim or any portion thereof.
VA FORM
EXISTING STOCKS OF VA FORM 21-22, NOV 2005,
COPY 3
JUN 2009 21-22
WILL BE USED.
OMB Control No. 2900-0321
Respondent Burden: 5 minutes
APPOINTMENT OF VETERANS SERVICE ORGANIZATION
AS CLAIMANT’S REPRESENTATIVE
Note - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, " Appointment of
Individual As Claimant’s Representative."
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.
1. LAST-FIRST-MIDDLE NAME OF VETERAN
2. VA FILE NUMBER (Include prefix)
3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)
3B. JOB TITLE OF OFFICIAL REPRESENTATIVE AUTHORIZED TO ACT ON VETERAN’S BEHALF
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
4. SOCIAL SECURITY NUMBER
5. INSURANCE NUMBER(S) (Include letter prefix)
6A. SERVICE NUMBER(S)
6B. BRANCH OF SERVICE
7. NAME OF CLAIMANT (If other than veteran)
8. RELATIONSHIP (If other than veteran)
9. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)
10. CLAIMANT’S TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME
B. EVENING
(
)
(
)
11. E-MAIL ADDRESS (If applicable)
12. DATE OF THIS APPOINTMENT
13. 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 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 3A 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 above,
either by explicit revocation or the appointment of another representative.
14. LIMITATION OF CONSENT - My consent in Item 13 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:
I, the claimant named in Items 1 or 7, hereby appoint the service organization named in Item 3A as my representative to prepare,
present and prosecute my claim for any and all benefits from the Department of Veterans Affairs based on the service of the veteran
named in Item 1. I authorize the Department of Veterans Affairs to release any and all of my records, to include disclosure of my
Federal tax information (other than as provided in Items 13 and 14), to that service organization appointed as my representative. It is
understood that no fee or compensation of whatsoever nature will be charged me for service rendered pursuant to this power of
attorney. I understand that the service organization I have appointed as my representative may revoke this power of attorney at any
time, subject to 38 CFR 20.608. Additionally, in those cases where a veteran’s income is being developed because of an income
verification necessitated by an Internal Revenue Service verification match, the assignment of the service organization as the
veteran’s representative is only valid for five years from the date this form is signed for purposes restricted to the verification match.
Signed and accepted subject to the foregoing conditions.
THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC
15. SIGNATURE OF CLAIMANT (Do Not Print)
16. DATE SIGNED
VA FORM 21-22-1 SENT TO:
DATE SENT
ACKNOWLEDGED
REVOKED (Reason and date)
VA
(Date)
CER
FILE
EDU
FILE
INSURANCE
USE
FILE
CH. 30
DEA FILE
LG FILE
ONLY
NOTE: As long as this appointment is in effect, the organization named herein will be recognized as the sole agent for presentation
of your claim before the Department of Veterans Affairs in connection with your claim or any portion thereof.
VA FORM
EXISTING STOCKS OF VA FORM 21-22, NOV 2005,
VHA COPY 4
JUN 2009 21-22
WILL BE USED.
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |