Form VA Form 21-0845 VA Form 21-0845 Authorization to Disclose Personal Beneficiary/Claimant

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION
TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY
GENERAL INFORMATION
At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept
confidential to the extent provided by law. In accordance with the Privacy Act and applicable confidentiality
statutes, VA will only disclose the information in its custody or control in the following circumstances: where
the individual identifies the particular information and consents to its use; where disclosure of the information
is required by law; or where the disclosure is otherwise legally permitted, including release for a purpose
compatible with the purpose for which it was collected.
By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit
information for any purpose that is not permitted by all applicable legal authorities. You may revoke your
written permission at any time, except if VA has already acted based on your permission.
SPECIFIC INSTRUCTIONS
Questions 1 - 6
In this section, give us your pertinent contact information to include name, address, contact numbers, and
e-mail address.
Question 7
Tell us the type of information you would like VA to release to your authorized third party.
Question 9
This section tells VA the duration of your consent. If you do not want your authorization to be effective
indefinitely, tell us when to stop releasing your personal benefit or claim information to your authorized third
party. Check the box that applies and fill in dates, if applicable.
Question 10
VA will give your personal benefit or claim information to the person or organization you fill in here. You may
only select one person or one organization. If you designate an organization, you must also identify one or
more individuals in that organization to whom VA may disclose your benefit or claim information. This form
cannot be used to disclose federal tax information to third parties.
Question 11
Select the security question you would like us to ask your designated third party and provide the answer.
This question will be asked each time your designated third party contacts our office.
Where Do I Send My Completed Form?
You can obtain the VA mailing address to send your completed, signed authorization by accessing our
Internet website at http://www.va.gov/directory or in the government pages of your telephone book under
"United States Government, Veterans."
You should make a copy of your signed authorization for your records before mailing it to VA. You can only
have one active VA Form 21-0845 on file with VA at a time.
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want VA to give out your personal benefit or claim information, you may
notify us in writing, or by telephone at 1-800-827-1000 or electronically via the Internet at https://iris.va.gov.
Upon notification from you VA will no longer give out benefit or claim information (except for the information
VA has already given out based on your permission).
VA FORM
MAY 2010

21-0845

(Continued on reverse)

OMB Approved No. 2900-0736
Respondent Burden: 5 minutes
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION
TO A THIRD PARTY

INSTRUCTIONS: Use this form if you want to give the Department of Veterans Affairs permission to
release your personal beneficiary or claim information to a third party. This form may not be executed by
any beneficiary recognized as incompetent for VA purposes, nor can VA accept this form from any
beneficiary recognized as incompetent for VA purposes.
1. FIRST, MIDDLE, LAST NAME OF VETERAN (Print clearly)

2. FIRST, MIDDLE, LAST NAME OF BENEFICIARY/CLAIMANT WHO IS NOT THE VETERAN

(Print clearly)

3. ADDRESS OF BENEFICIARY/CLAIMANT (No. and Street or rural route, City or P.O., State and ZIP Code)
5. SOCIAL SECURITY NUMBER

4. VA FILE NUMBER

6. CONTACT INFORMATION
A. DAYTIME PHONE NUMBER

C. E - MAIL ADDRESS (If applicable)

B. CELL PHONE NUMBER

7. I (beneficiary/claimant) authorize the Department of Veterans Affairs (VA) to contact the person or organization listed below for the purposes
of providing the following information pertaining to my VA record. (Check only one box below to tell VA the specific benefit or claim information
you want disclosed.)
Any Information (Go to Item 9)

Limited Information (Go to Item 8)

8. IF YOU SELECTED "LIMITED INFORMATION", CHECK ALL THAT APPLY

Status of pending claim or appeal

Amount of money owed VA

Other

Current benefit and rate

Request a benefit payment letter

Payment history

Change of address or direct deposit

9. IF YOU SELECTED "ANY INFORMATION", THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE:

From the date of signing below until

One time only

(Specify date - month, day, year)

Ongoing until written notice is given to VA to terminate

10. VA IS AUTHORIZED TO DISCLOSE THE INFORMATION AS SPECIFIED ABOVE TO THE PERSON OR ORGANIZATION LISTED BELOW. NOTE: IF
AUTHORIZATION IS FOR AN ORGANIZATION, PLEASE PROVIDE THE FIRST AND LAST NAME OF THE ORGANIZATION'S REPRESENTATIVE. (Please print clearly)
A. NAME OF PERSON OR ORGANIZATION

B. ADDRESS OF PERSON OR ORGANIZATION

11. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY
QUESTION BOX IN 11A AND PROVIDE THE ANSWER IN 11B.
B. ANSWER

A. SECURITY QUESTION

The city and state your mother was born in
The name of the high school you attended
Your first pet's name
Your favorite teacher's name
Your father's middle name
12A. SIGNATURE (Do NOT print)

12B. DATE SIGNED

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, 58VA21/22/28 Compensation, Pension, Education,
and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. 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. The 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.
RESPONDENT BURDEN: We need this information to release your private benefit and/or claim information to a designated third party(ies). The execution of this form
does not authorize the release of information other than that specifically described. The information requested on this form will authorize release of the information you
specify. 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.
VA FORM
MAY 2010

21-0845

SUPERSEDES VA FORM 21-0845, DEC 2009, WHICH
WILL NOT BE USED.