Form VA 21-4193 VA 21-4193 Notice to Department of Veterans Affairs of Veteran or B

OMB Approved No. 2900-0116
Respondent Burden: 15 minutes
Expiration Date: XX-XX-XXXX
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)

NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR
BENEFICIARY INCARCERATED IN PENAL INSTITUTION
NOTE: Pursuant to Title 38, U.S.C., 1505, 3482, 3680 and 5313, awards of Department of
Veterans Affairs benefits for veterans and beneficiaries are subject to adjustment or
discontinuance while such persons are incarcerated.
NAME AND ADDRESS OF INSTITUTION

FROM

TO

SECTION I - IDENTIFICATION INFORMATION

NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly, and legibly to help process the form.
2. VETERAN/BENEFICIARY's NAME (First, Middle Initial, Last)

3. SOCIAL SECURITY NUMBER

4. VA FILE NUMBER

5. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
Day

Month

Year

7. RELATIONSHIP TO VETERAN

6. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II: INFORMATION ABOUT INCARCERATION
8. DATE OFFENSE WAS COMMITTED (MM/DD/YYYY) 9. TYPE OF OFFENSE FOR WHICH COMMITTED
Month

Day

Year

Month
FELONY

11. LENGTH OF SENTENCE

Day

Year

MISDEMEANOR

12. SCHEDULED RELEASE DATE (MM/DD/YYYY)
Month

13A. IS INDIVIDUAL IN A WORK RELEASE OR HALFWAY HOUSE PROGRAM?

Day

Year

13B. DATE ENTERED PROGRAM (MM/DD/YYYY)
Month

YES

10. DATE OF CONFINEMENT FOLLOWING CONVICTION
(MM/DD/YYYY)

Day

Year

NO

SECTION III: REMARKS

VA FORM
XXX XXXX

21-4193

EXISTING STOCK OF VA FORM 21-4193, JUN 2014,
WILL BE USED.
Page 1 of 2

VETERAN'S SOCIAL SECURITY NO.
REMARKS (Continued)

SECTION IV: SIGNATURE OF OFFICIAL
14. NAME AND TITLE OF INSTITUTIONAL OFFICIAL

16. SIGNATURE OF INSTITUTIONAL OFFICIAL

15. DATE SIGNED (MM/DD/YYYY)

17. INSTITUTION TELEPHONE NUMBER
(Include Area Code)

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, and published in the Federal Register. Your obligation to respond is voluntary.
Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine the adjustment or discontinuance of VA benefits for veterans and beneficiaries who are incarcerated.
Title 38, United States Code 1505, 3482, 3680, and 5313, 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
http: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
XXX XXXX

21-4193
Page 2 of 2

DEPARTMENT OF VETERANS AFFAIRS

Where to Send Your Written Correspondence
In order to properly determine where to send your written correspondence, please first
identify your benefit type (Compensation, Veterans Pension, or Survivors Benefits); then,
locate the corresponding address based on your location of residence.
For correspondence relating to all Compensation claims:
Address
Location of Residence
Department Of Veterans
All United States and Foreign Locations
Affairs Evidence Intake Center
P.O. Box 4444
Janesville WI 53547-4444
*Note: For foreign Veterans Pension and Survivors
Benefits please refer to the below addresses.

Or fax your information to:
Toll Free: 844-531-7818
Local: 248-524-4260

For correspondence relating to all Veterans Pension and Survivors Benefits claims:
Alabama
Arkansas
Illinois
Indiana

Alaska
Arizona
California
Colorado
Hawaii
Idaho
Iowa
Kansas
Minnesota

Location of Residence
Kentucky
Missouri
Louisiana
Ohio
Michigan
Tennessee
Mississippi
Wisconsin

Montana
Nebraska
Nevada
New Mexico
North Dakota
Oklahoma
Oregon
South Dakota

Texas
Utah
Washington
Wyoming
Mexico
Central America
South America
Caribbean

Address
Department Of Veterans
Affairs Claims Intake Center
Attention: Milwaukee Pension
Center
P.O. Box 5192
Janesville WI 53547-5192
Or Fax your information to:
Toll Free: (844) 655-1604
Department Of Veterans
Affairs Claims Intake Center
Attention: St. Paul Pension
Center
P.O. Box 5365
Janesville WI 53547-5365
Or fax your information to:
Toll Free: (844) 655-1604

Department Of Veterans
South Carolina
Affairs
Vermont
Claims Intake Center
Virginia
Attention: Philadelphia Pension
West Virginia
Center
District of Columbia
P.O. Box 5206
Puerto Rico
Janesville WI 53547-5206
Canada
Or fax your information to:
Toll Free: (844) 655-1604
Countries outside of North, Central or South America
Connecticut
Delaware
Florida
Georgia
Maine
Maryland
Massachusetts

New Hampshire
New Jersey
New York
North Carolina
Pennsylvania
Rhode Island