21-10210 Lay/Witness Statement

OMB Approved No. 2900-0881
Respondent Burden: 10 Minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

LAY/WITNESS STATEMENT
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use this form to
submit a statement as a veteran/claimant or someone writing on your behalf to support a claim. If you or someone else
writing on your behalf are providing additional statement(s) to support your claim(s) please submit this form with your
application. For more information, contact us at https://iris.custhelp.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 forms are available at
www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.
O. Box 4444, Janesville, WI 53547-4444.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box,
and completely fill in each applicable circle to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

5. VA INSURANCE FILE NUMBER (If applicable)

6. CURRENT MAILING ADDRESS (If applicable) (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

7. TELEPHONE NUMBER (Include Area Code)

8. E-MAIL ADDRESS

I agree to receive electronic correspondence from VA in regards to my claim.

Enter International Phone Number

(If applicable)

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION

(Complete this section ONLY IF the claimant is NOT the veteran)
9. CLAIMANT'S NAME (First, Middle Initial, Last)

11. VA FILE NUMBER (If applicable)

10. SOCIAL SECURITY NUMBER

12. DATE OF BIRTH (MM/DD/YYYY)
Month

Day

Year

13. VA INSURANCE FILE NUMBER (If applicable)

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

15. TELEPHONE NUMBER (Include Area Code)

ZIP Code/Postal Code
16. E-MAIL ADDRESS

I agree to receive electronic correspondence from VA in regards to my claim.

Enter International Phone Number

(If applicable)

VA FORM
XXX XXXX

21-10210

SUPERSEDES VA FORM 21-10210, JUN 2021.

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SOCIAL SECURITY NUMBER

SECTION III: STATEMENT

(Use this section to submit your statement, or a statement from someone else writing on your behalf)
NOTE: Please indicate the claimed issue that you are addressing. If you would like to submit an additional statement on your own behalf or if you have more than
one witness writing on your behalf, use a separate form (VA Form 21-10210) for each statement.
17. STATEMENT (Note: Describe what you yourself know or have observed about the facts or circumstances relevant to this claim before VA)

VA Form 21-10210, XXX XXXX

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SOCIAL SECURITY NUMBER

SECTION III: STATEMENT (Continued)
(Use this section to submit your statement, or a statement from someone else writing on your behalf)
NOTE: Please indicate the claimed issue that you are addressing. If you would like to submit an additional statement on your own behalf or if you have more than
one witness writing on your behalf, use a separate form (VA Form 21-10210) for each statement.
17. STATEMENT (Note: Describe what you yourself know or have observed about the facts or circumstances relevant to this claim before VA)

SECTION IV: WITNESS CONTACT INFORMATION

(Complete Section IV and V if the statement in Section III is from someone else writing on your behalf)
18. WITNESS NAME (First, Middle Initial, Last)

19. RELATIONSHIP TO VETERAN/CLAIMANT (Check all that apply)
SERVED WITH VETERAN/CLAIMANT

FAMILY/FRIEND OF VETERAN/CLAIMANT

COWORKER/SUPERVISOR OF VETERAN/CLAIMANT

OTHER (Specify)
20. TELEPHONE NUMBER (Include Area Code)

21. E-MAIL ADDRESS

Enter International Phone Number

(If applicable)

SECTION V: CERTIFICATION OF STATEMENT AND SIGNATURE
I CERTIFY THAT I have completed this statement and that its information is true and correct to the best of my knowledge and belief.
22A. VETERAN/CLAIMANT/WITNESS SIGNATURE (REQUIRED)

22B. DATE SIGNED (MM/DD/YYYY)
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 and Veteran Readiness and Employment Records -VA, published in
the Federal Register. Your obligation to respond is voluntary.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0881, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 10 minutes
per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA
Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0881 in any correspondence. Do not send your completed VA Form 21-10210 to
this email address.

VA Form 21-10210, XXX XXXX

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