VA Form 27-0820e Report of Incarceration

OMB Approved No. 2900-0734
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX

REPORT OF INCARCERATION
NOTE - This form must be filled out in ink or on a computer, as it
becomes a permanent record in the veteran's folder.

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

1. VA OFFICE

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

4. DATE OF CONTACT (Month, day, year)

5. NAME AND TITLE OF PERSON CONTACTED

6. TYPE OF CONTACT
PERSONAL

7. NAME AND ADDRESS OF INSTITUTION OR FACILITY CONTACTED (Check appropriate box)
FEDERAL

STATE

TELEPHONE

8. TELEPHONE NUMBER OF PERSON CONTACTED

(Include Area Code)

9. BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (If needed, continue on a separate sheet)
I contacted the above-named penal institution to confirm and document the following information.

(Complete two or more)
VETERAN'S SOCIAL SECURITY NUMBER

DATE OF BIRTH

DEPARTMENT OF CORRECTIONS INMATE NUMBER
DATE OF CONVICTION

(Month, day, year)

FELONY

NO ACTION NECESSARY

MISDEMEANOR

DATE OF CONFINEMENT
AFTER CONVICTION

(Month, day, year)

DATE OF
RELEASE

(Month, day, year)

TYPE OF RELEASE

FURTHER ACTION NEEDED

10. ADDITIONAL REMARKS

A copy of this form was sent to Power of Attorney of record (If applicable)
cc:
DIVISION OR SECTION

EXECUTED BY (Signature and title)

PRIVACY ACT NOTICE: The 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 5, 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 to required to obtain or retain benefits. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
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 2900-0734, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 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. 2900-0734 in any correspondence. Do not send your completed VA Form 27-0820e to this email address.
VA FORM
XXX XXXX

27-0820e

SUPERSEDES VA FORM 27-0820e, DEC 2021,
WHICH WILL NOT BE USED.