Form FL 21-30 FL 21-30 Request for Contact Information

DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

•

File number:
Veteran:
Beneficiaries:

A representative from our office will contact you in the near future.

To assist us in arranging this meeting, please complete the form on the reverse side of this letter

and return it in the enclosed envelope.

Your prompt reply will be appreciated.

Sincerely yours,

Enclosure

FL 21-30

JUL 2011 (R)

OMB Approved No. 2900·0660

Respondent Burden: 15 Mins.

CONTACT INFORMATION
Privacy Act Notice: The 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. The responses you submit are considered confidential (38 U.S.C.
5701).
Respondent Burden: We need this information to assist VA in arranging a meeting to discuss with you matters of interest to you
and the VA (38 U.S.C. Chapters 55 and 57). Title 38, United States Code, 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 Intemet
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.
HOME ADDRESS (If different from that on reverse) (If you serve as payee for a VA beneficiary, please provide that person's address if different than
your own)

IFYOU
WILL
BEAT
HOME ~
DU RI NG TH E
DAY,
PLEASE
GIVE

DIRECTIONS TO YOUR HOME (If living in a RURAL AREA, give directions from nearest town, and include directions, i.e., north, south, etc., and
highway names and numbers, mileage, and landmarks. If living in a town or city, give directions from a main intersection, a conspicuous landmark,
etc. Please draw a map if it will be helpful.)

HOME TELEPHONE NO. (Include Area Code)

BUSINESS, FIRM OR OTHER NAME AND ADDRESS WHERE YOU CAN BE CONTACTED (Include hours worked)

IFYOU
WILL NOT
BEAT
HOME ~
DURING THE I - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - j
TELEPHONE NO. WHERE YOU CAN BE REACHED (Include Area Code)
DAY,
PLEASE
GIVE
DATE

ISIGNATURE

FL 21-30, JUL 2011 (R)