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 WRITEIN 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. See Page 3 for information on how
to submit this form.
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
Day

Month

Year

Month
FELONY

11. LENGTH OF SENTENCE

Day

MISDEMEANOR

Year

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, NOV 2017,
WILL BE USED.

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VETERAN'S SOCIAL SECURITY NO.
REMARKS (Continued)

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

16. SIGNATURE OF INSTITUTIONAL OFFICIAL (Sign in ink)

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 Veteran Readiness and Employment Records - VA, 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 21-4193, XXX XXXX

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Where to Send Your Written Correspondence
Documents may be submitted by mail, in person at a VA regional office or electronically. However, VA
recommends submitting correspondence electronically as this is the fastest method of receipt.
VA provides several tools to assist in electronic submission. To learn more about how to submit documents and
claims electronically, visit www.va.gov/disability/upload-supporting-evidence. You can also go directly to
access.va.gov to digitally upload any correspondence using Direct Upload.
By visiting www.va.gov you can also check your claims status and learn about other VA benefits.
If you need assistance, you can find a local, accredited representative at https://www.benefits.va.gov/vso/.
If you prefer to mail your correspondence, please use the related mailing address below.
COMPENSATION CLAIMS
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444

FIDUCIARY
Department of Veterans Affairs
Fiduciary Intake
PO Box 95211
Lakeland, FL 33804-5211

PENSION & SURVIVORS BENEFIT CLAIMS
Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365

BOARD OF VETERANS' APPEALS
Department of Veterans Affairs
Board of Veterans' Appeals
PO Box 27063
Washington, DC 20038

These addresses serve all United States and foreign locations.

VA FORM 21-4193, XXX XXXX

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