Form 21 Application for Accreditation as Service Organization Re

Form Approved: OMB No. 2900-0018
Respondent Burden: 15 minutes

APPLICATION FOR ACCREDITATION AS SERVICE ORGANIZATION REPRESENTATIVE
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE: The information requested on this form is solicited under 38 U.S.C., Section 5902, which authorizes
VA to recognize representatives of approved organizations for the preparation, presentation, and prosecution of claims under laws administered by VA. The requested
information will enable VA to determine your eligibility for accreditation as a representative of a recognized service organization. Your disclosure of this information to us is
voluntary, but your failure to provide full information could delay or preclude your accreditation. The Privacy Act authorizes VA to disclose the information outside VA for
certain routine uses, which have been published in the Federal Register with reference to a VA system of records entitled, "Current and Former Accredited Representative,
Claims Agent, and Representative and Claims Agent Applicant and Rejected Applicant Records-VA" (01VA022). Such routine uses include verification of the identity,
status, and service organization affiliation of representatives, civil or criminal law enforcement, communnications with members of Congress of their representatives,
Government litigation, and notification to service organizations of information relevant to a refusal to grant or a suspension or termination of accreditation.
RESPONDENT BURDEN: VA may not conduct or sponsor, and you are not required to respond to, this collection of information unless it displays a valid OMB Control
Number. The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to VA Clearance Officer (005G2), 810 Vermont Avenue, NW,
Washington, DC 20420. Send comments only. Do not send this form or requests for benefits to this address.
SECTION I - TO BE EXECUTED BY DESIGNEE (Type or print)
1. LAST NAME - FIRST NAME - MIDDLE NAME

2. BUSINESS ADDRESS

3. BRANCH OF SERVICE (Check applicable boxes)
ARMY

NAVY

AIR FORCE

MARINE CORPS

COAST GUARD

OTHER (Specify)

NON-VETERAN

4. LIST OF DATES OF ALL ACTIVE SERVICE 5. CHARACTER OF DISCHARGE(S)

6. METHOD OF QUALIFICATION
COMPLETED APPROPRIATE TRAINING
EXPERIENCE REPRESENTING CLAIMANTS

7A. NAME OF ORGANIZATION WHICH YOU WILL REPRESENT

7B. RELATIONSHIP TO ORGANIZATION
ARE YOU A MEMBER IN GOOD STANDING
OF THE ORGANIZATION SHOWN IN
ITEM 7A?

YES

7C. COUNTY VETERANS SERVICE OFFICERS

ARE YOU A PAID EMPLOYEE OF THE ORGANIZATION SHOWN
IN ITEM 7A, WORKING FOR THE ORGANIZATION FOR NOT
LESS THAN 1000 HOURS ANNUALLY?

NO

YES

ARE YOU A PAID COUNTY EMPLOYEE: 1) WHO WORKS
FOR THE COUNTY NOT LESS THAN 1000 HOURS
ANNUALLY; B) WHO HAS SUCCESSFULLY COMPLETED
VA-APPROVED STATE TRAINING AND EXAMINATION;
AND C) WHO WILL RECEIVE REGULAR STATE
SUPERVISION AND MONITORING OR ANNUAL TRAINING?

NO

YES

NO

8. ARE YOU ACCREDITED TO ANY OTHER ORGANIZATION(S)?
NO (If "YES," give name of organization(s))

YES

9A. ARE YOU EMPLOYED IN ANY CIVIL OR MILITARY DEPARTMENT OR
AGENCY OF THE UNITED STATES GOVERNMENT?
YES
NO (If "YES," give name of agency or department)

9B. HAVE YOU EVER HELD A FEDERAL GOVERNMENT POSITION WHICH INVOLVED
ANY ACTION RESPECTING CLAIMS IN THE DEPARTMENT OF VETERANS AFFAIRS
OR THE VETERANS ADMINISTRATION?
YES

NO

It is understood and agreed that neither the designee nor the organization will charge or accept any fee or other gratuity for services rendered a claimant;
that neither will publish or divulge any confidential information except as provided by law or regulation; and that any breach of these conditions will be
sufficient basis for revocation of accreditation.
10. SIGNATURE OF DESIGNEE (NEW CERTIFICATIONS ONLY)

11. DATE OF SIGNATURE

SECTION II - TO BE EXECUTED BY PROPER CERTIFYING OFFICER OF RECOGNIZED ORGANIZATION

CERTIFICATION: Subject to the foregoing agreement, the undersigned hereby certifies that the designee is of good character and reputation, is
qualified by training or experience to present claims, and that the foregoing statements are believed to be correct.
We therefore recommend accreditation.
We recertify the qualifications of this representative.
12. SIGNATURE AND TITLE OF CERTIFYING OFFICER

13. NAME OF ORGANIZATION

14. ADDRESS OF CERTIFYING OFFICER

15. DATE OF SIGNATURE

PENALTY: The law provides that whoever makes any statement of a material fact, knowing it to be false, shall be punished by a fine or imprisonment or
both (18 U.S.C. 1001).
VA FORM
JUL 2007

21

Supersedes VA Form 21, JUN 1992, Which Will Not Be Used.

Adobe Live Cycle Designer 7.1