Form VA Form 21-0972 VA Form 21-0972 Alternate Signer Certification

NOTICE TO VETERAN/CLAIMANT OF VA FORMS THAT MAY ACCOMPANY
AN ALTERNATE SIGNER CERTIFICATION FORM
IMPORTANT: The form(s) shown in the table below will be accepted along with the attached VA Form 21-0972, Alternate Signer
Certification. VA forms are available at www.va.gov/vaforms..
For:

Required Form(s):
VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits

COMPENSATION

VA Form 21-526b, Veteran's Supplemental Claim for Compensation
VA Form 21-526c, Pre-Discharge Compensation Claim
VA Form 21-527EZ, Application for Pension
VA Form 21-527, Income, Net Worth, and Employment Statement
VA Form 21P-0969, Income and Asset Statement in Support of Claim for Pension or Parents' Dependency
and Indemnity Compensation (DIC)

PENSION

VA Form 21P-4165, Pension Claim Questionnaire for Farm Income
VA Form 21-8049, Request for Details of Expenses
VA Form 21P-8416, Medical Expense Report
VA Form 21-4185, Report of Income from Property or Business
ALL forms known as Eligibility Verification Reports (EVR's)

COMPENSATION AND/OR
PENSION

VA Form 21-526, Veterans Application for Compensation and/or Pension

DEPENDENTS

VA Form 21-686c, Add Dependent's to Award, and VA Form 21-686r, Request to remove Dependent

SCHOOL AGE CHILD(REN)

(Aged 18-23 Years and In School)

DEPENDENT PARENT(S)
INDIVIDUAL UNEMPLOYABILITY

VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

VA Form 21-674, Request for Approval of School Attendance
VA Form 21P-509, Statement of Dependency of Parent(s)
VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability

POST-TRAUMATIC STRESS
DISORDER

VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress
Disorder (PTSD) and VA Form 21-0781a, Statement in Support of Claim for Service Connection for PTSD
Secondary to Personal Assault

SPECIALLY ADAPTED HOUSING
OR SPECIAL HOME ADAPTATION

VA Form 26-4555, Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant

AUTO ALLOWANCE

VA Form 21-4502, Application for Automobile or Other Conveyance and Adaptive Equipment
VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits
VA Form 21-534, Application for Dependency and Indemnity Compensation, Death Pension, and Accrued
Benefits by Surviving Spouse or Child

SURVIVORS BENEFITS

VA Form 21-534a, Application for Dependency and Indemnity Compensation by a Surviving Spouse or
Child - In-Service Death Only
VA Form 21-535, Application for Dependency and Indemnity Compensation by Parent(s)
VA Form 21-8924, Application of Surviving Spouse or Child for REPS Benefits (Restored Entitlement
Program for Survivors)

ACCRUED BENEFITS
PHILIPPINE CLAIMS

VA Form 21-601, Application for Accrued Amounts Due a Deceased Beneficiary
VA Form 21-0704, Supplemental Income Questionnaire
VA Form 21-4169, Supplement to VA Forms 21-526, 21-534, and 21-535

BENEFITS FOR CERTAIN
CHILDREN WITH DISABILITIES

VA Form 21-0304, Application for Benefits for Certain Children with Disabilities Born of Vietnam and
Certain Korea Service Veterans

NOTE: For more information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us
toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.
VA FORM 21-0972, XXX XXXX

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OMB Control No. 2900-XXXX
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

DRAFT

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

ALTERNATE SIGNER CERTIFICATION
INSTRUCTIONS: This form is to be completed by the individual signing the benefit application form on
behalf of the veteran/claimant. Note: For purposes of this form, the individual signing the form on behalf
of the veteran/claimant is referred to as the "alternate signer." Your accurate and complete answers to the
questions on this form are important to help VA complete the veteran/claimant's claim.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You can either complete the form online or by hand. Please print your information using blue or black ink, neatly, and legibly to help process the form.
IMPORTANT: Submit this form along with the appropriate benefit application form. The application form depends on the benefit you are claiming on behalf
of the veteran/claimant. Also, submit any supporting documents or evidence to help VA complete the claim. See page 1 for a list of appropriate benefit
application forms.

1. VETERAN'S NAME (First, middle initial, last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

5. HAS THE VETERAN EVER FILED A CLAIM WITH VA?
YES

4. VETERAN'S DATE OF BIRTH
Month

Day

Year

6. VETERAN'S SERVICE NUMBER (If applicable)

NO

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION (Complete This Section If The Claimant is Other Than The Veteran)
7. CLAIMANT'S NAME (First, middle initial, last)

8. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

10. CLAIMANT'S RELATIONSHIP TO VETERAN

9. CLAIMANT'S SOCIAL SECURITY NUMBER

SPOUSE

11. CLAIMANT'S PREFERRED TELEPHONE NUMBER (Include Area Code)

PARENT

CHILD

12. CLAIMANT'S PREFERRED E-MAIL ADDRESS (If applicable)

SECTION III: ALTERNATE SIGNER'S IDENTIFICATION INFORMATION
13. ALTERNATE SIGNER'S NAME (First, middle initial, last)

14. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

15. ALTERNATE SIGNER'S PREFERRED TELEPHONE NUMBER (Include Area Code)

16. ALTERNATE SIGNER'S PREFERRED E-MAIL ADDRESS
(If applicable)

17. ALTERNATE SIGNER'S RELATIONSHIP TO VETERAN/CLAIMANT (Note: You must check at least one box)
A COURT-APPOINTED REPRESENTATIVE
AN ATTORNEY IN FACT OR AGENT AUTHORIZED TO ACT ON
BEHALF OF THE VETERAN/CLAIMANT UNDER DURABLE POWER
OF ATTORNEY
VA FORM
XXX XXXX

21-0972

A PERSON WHO IS RESPONSIBLE FOR THE CARE OF THE VETERAN/CLAIMANT,
TO INCLUDE BUT NOT LIMITED TO A SPOUSE OR OTHER RELATIVE
A MANAGER OR PRINCIPAL OFFICER ACTING ON BEHALF OF AN INSTITUTION
WHICH IS RESPONSIBLE FOR THE CARE OF THE VETERAN/CLAIMANT

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VETERAN'S SSN

SECTION IV: VETERAN/CLAIMANT INFORMATION
18. VETERAN/CLAIMANT IS: (Check ALL that apply)
UNDER 18 YEARS OF AGE
MENTALLY INCOMPETENT TO PROVIDE SUBSTANTIALLY ACCURATE INFORMATION NEEDED TO COMPLETE THE CLAIMS FORM, OR TO CERTIFY
THAT STATEMENTS MADE ON THE FORM ARE TRUE AND COMPLETE, OR
PHYSICALLY UNABLE TO SIGN THE CLAIMS FORM

SECTION V: ALTERNATE SIGNER'S DECLARATION OF INTENT

I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under
penalty of perjury. I also understand that VA may request further documentation or evidence to verify or confirm
my authorization to sign or complete an application on behalf of the veteran/claimant if necessary. Examples of
evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN);
a certificate or order from a court with competent jurisdiction showing my authority to act for the veteran/
claimant with a judge's signature and date/time stamp; copy of documentation showing appointment of fiduciary;
durable power of attorney showing the name and signature of the veteran/claimant and my authority as attorney
in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person
responsible for the care of the veteran/claimant indicating the capacity or responsibility of care provided; or any
other documentation showing such authorization.
19A. AUTHORIZED SIGNER'S SIGNATURE (Required)

19B. DATE SIGNED (MM,DD,YYYY)

20. REMARKS (If any)

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 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 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 requested information is considered relevant and necessary to determine the
appropriate application and provide it to the veteran/claimant.
RESPONDENT BURDEN: We need this information to determine entitlement to act as the alternate signer for a veteran/claimant in submitting a claim for
VA benefits (38 U.S.C. 5101). 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 Internet 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.
VA FORM 21-0972, XXX XXXX

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