20-10206 Freedom of Information Act (FOIA) or Privacy Act (PA) Re

INFORMATION AND INSTRUCTIONS ON HOW TO SUBMIT
A FREEDOM OF INFORMATION ACT (FOIA) OR PRIVACY ACT REQUEST (PA)
IMPORTANT: This form is ONLY used to request military records or a veteran's benefit records.

Please complete the attached form to submit a Freedom of Information Act (FOIA) or Privacy Act (PA) request. It must be
signed by the requester, veteran or third-party authorized to act on behalf of the requester.
WHAT IS A FOIA REQUEST?
A FOIA request provides the public the right to request access to records from Federal agencies, except those protected by
the nine FOIA exemptions. For additional information please visit https://www.va.gov/FOIA/index.asp.
WHAT IS A PA REQUEST?
A citizen of the United States or an alien lawfully admitted for permanent residence may request access to or amendment of
records on herself/himself from a System of Records (SORs). Examples of PA records are personal Claims Files (C-File),
educational loan, and beneficiary records. For additional information please visit https://www.oprm.va.gov/privacy/.
VERIFICATION OF IDENTITY AND CONSENT FOR PA REQUESTS ONLY
A request must include the following information:
• Your full name;
• Your date of birth;
• Your place of birth;
• Your current mailing address; and
• Handwritten signature is required
Note: To help us locate requested records, please include your Social Security number (SSN) or Alien Registration number
(A-number).

WHERE TO SEND YOUR REQUEST:
NOTE - All Privacy Act requests must be sent to the Centralized Support Division address listed below.

VA FORM
OCT 2020

20-10206

RECORDS CUSTODIAN

MAIL or FAX TO

Centralized Support Division
Claim Files, Service Treatment Records/
Military Treatment Records,
DD Form 214, C&P Exams etc.

Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
Toll-free Phone: 1-800-827-1000
Toll-free Fax: (844) 531-7818

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OMB Approved No. 2900-0877
Respondent Burden: 5 Minutes
Expiration Date: 10/31/2023

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

FREEDOM OF INFORMATION ACT (FOIA) OR PRIVACY ACT(PA) REQUEST
INSTRUCTIONS: Read the Privacy Act and Respondent Burden information on Page 4 before completing the
form. This form must be signed by the requester, authorized organization, or third party who has been authorized
by the requester. For additional information on VA FOIA and PA requests visit our website at https://www.va.gov/
FOIA/Requests.asp. You may also contact the VA at https://www.va.gov/contact-us 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 forms are available at www.va.gov/vaforms.

SECTION I: REQUEST FOR INFORMATION ON YOURSELF
(If you are seeking information on yourself, complete Sections I, III or IV, VI, VII and VIII. Complete Section VI, if applicable)
NOTE: You may complete the form on-line or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and completely fill in each applicable
circle to help expedite processing of the form.
1. NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. ALIEN REGISTRATION NUMBER (A-number) (If applicable)

5. DATE OF BIRTH

6. PLACE OF BIRTH (Provide City and State, County and State or City and Country)
Year

Day

Month

4. VA FILE NUMBER (If applicable)

7. 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
ZIP Code/Postal Code

Country

8A. TELEPHONE NUMBER (Include Area Code)

8B. FAX NUMBER (If applicable)

Enter International Phone Number
(If applicable)
9. E-MAIL ADDRESS

Enter International FAX Number
(If applicable)

I agree to receive electronic correspondence from VA.

SECTION II: REQUEST FOR INFORMATION ON A PERSON OTHER THAN YOURSELF
(If you are seeking information on an individual other than yourself, complete Sections II, III or IV, V, VII and IX or X.
Complete Section VI, if applicable)

10. NAME (First, Middle Initial, Last) OR YOUR ORGANIZATION'S NAME

11. 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

12A. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number
(If applicable)
VA FORM
OCT 2020

20-10206

ZIP Code/Postal Code
12B. FAX NUMBER (If applicable)

Enter International FAX Number
(If applicable)

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SOCIAL SECURITY NUMBER

SECTION II: REQUEST FOR INFORMATION ON A PERSON OTHER THAN YOURSELF (Continued)
(If you are seeking information on an individual other than yourself, complete Sections II, III or IV, V, VII and IX or X.
Complete Section VI, if applicable)
NOTE: Items 13 through 16 must be completed to inform VA on whom the person is you are requesting the information about.
13. NAME OF THE PERSON YOU ARE REQUESTING INFORMATION ON (First, Middle Initial, Last)

14. SOCIAL SECURITY NUMBER

15. ALIEN REGISTRATION NUMBER (A-number) (If applicable)

16. VA FILE NUMBER (If applicable)

SECTION III: COMPENSATION AND PENSION RECORDS REQUEST
(This information is required in order to complete the request)
17. SELECT THE TYPE(S) OF RECORDS YOU ARE REQUESTING, BELOW:
CLAIMS FILE (C-FILE)

SERVICE TREATMENT RECORDS / MILITARY TREATMENT RECORDS

DISABILITY EXAMINATIONS (C & P EXAMS) (If applicable enter date of exam in Section VI, Item 20, Remarks)

DD FORM 214
PENSION BENEFIT DOCUMENTS

OFFICIAL MILITARY PERSONNEL FILE (OMPF)

OTHER (Specify): ________________________________________________

SECTION IV: ALL OTHER BENEFIT RECORDS REQUEST
(This information is required in order to complete the request)
18. SELECT THE TYPE(S) OF RECORDS YOU ARE REQUESTING, BELOW:
VOCATIONAL
REHABILITATION AND
EMPLOYMENT RECORDS
EDUCATION BENEFIT RECORDS

HOME LOAN BENEFIT RECORDS

FIDUCIARY SERVICES RECORDS

OTHER (Specify):_____________________________________

FINANCIAL RECORDS (If applicable,
specify which records are being requested
in Section VI, Item 20, Remarks)
LIFE INSURANCE BENEFIT RECORDS (If
applicable, enter policy number in Section VI,
Item 20, Remarks)

SECTION V: VA REGIONAL OFFICE INFORMATION (If known)
19. PROVIDE NAME OF VA REGIONAL OFFICE YOU ARE ASSOCIATED WITH

SECTION VI: REMARKS
20. REMARKS (If any)

SECTION VII: WILLINGNESS TO PAY FEES
21. IMPORTANT: For the purpose of fees only, FOIA divides requesters into three categories: (1) commercial requesters may be charged fees for
searching for records, reviewing the records, and photocopying them; (2) educational, non-commercial scientific institutions, and representatives of the
news media are charged for photocopying after the first 100 pages; (3) all other requesters (requesters who do not fall into any of the other two
categories) are charged for photocopying after the first 100 pages and for time spent searching for records in excess of two hours. VA charges $0.15 per
single-sided page for photocopying. Actual costs are charged for a format other than paper copies.
An agency may grant fee waivers if the requester successfully demonstrates that disclosure of information is in the publics interest because it is likely to
contribute significantly to the public understanding of the operations or activities of the government and is not primarily in the commercial interest of the
requester.
I AM WILLING TO PAY THE APPLICABLE FEES UP TO THE AMOUNT OF

$

.00

IF YOU BELIEVE YOU ARE ENTITLED TO A FEE WAIVER OR EXPEDITED PROCESSING, INDICATE HERE:

VA Form 20-10206, OCT 2020

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SOCIAL SECURITY NUMBER

SECTION VIII: REQUESTER CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have completed this FOIA/PA request and declare it is true and correct to the best of my knowledge and belief.
22A. REQUESTER'S SIGNATURE (REQUIRED) (SIGN IN INK)

22B. DATE SIGNED
Month

Day

Year

SECTION IX: THIRD-PARTY CERTIFICATION AND SIGNATURE
(Valid only if Section II has been completed and requester has an authorized third party)
I CERTIFY THAT the requester has authorized me as the undersigned representative and certifies that the truth and completion of the
information contained in this document is to the best of the requesters knowledge and belief.
NOTE: A third-party signature will not be accepted unless a valid VA Form 21-0845, Authorization to Disclose Personal Information to a Third Party is of
record or completed and attached to this request. A third-party may be a family member or other designated person who is not a Power of Attorney,
agent, or fiduciary.
23A. THIRD-PARTY SIGNATURE

23B. DATE SIGNED
Month

Day

Year

SECTION X: POWER OF ATTORNEY (POA) CERTIFICATION AND SIGNATURE
(Valid only if Section II has been completed and requester has authorized POA representation)
I CERTIFY THAT the requester has authorized me as the undersigned representative and certifies the truth and completion of the information
contained in this document to the best of the requesters knowledge and belief.
NOTE: A POA's signature will not be accepted unless a valid VA Form 21-22, Appointment of Veterans Service Organization as Claimant's
Representative or VA Form 21-22a, Appointment of Individual as Claimant's Representative is of record or attached to this request.
24A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE)

24B. DATE SIGNED
Month

Day

Year

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a
material fact knowing it to be false, or for fraudulent receipt of any document to which you are not entitled.

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 VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, Veteran Readiness and Employment
Records - VA, published in the Federal Register. Your obligation to respond is voluntary.
RESPONDENT BURDEN: We need this information to identify and obtain the information you are requesting. 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.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 20-10206, OCT 2020

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