Va Form 21-0845 Authorization To Disclose Personal Information Page 2

Download a blank fillable Va Form 21-0845 Authorization To Disclose Personal Information in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0845 Authorization To Disclose Personal Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

OMB Approved No. 2900-0736

Respondent Burden: 5 minutes

(DO NOT WRITE IN THIS SPACE)

(VA DATE STAMP)

AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION

TO A THIRD PARTY

INSTRUCTIONS: Use this form if you want to give the Department of Veterans Affairs permission to

release your personal beneficiary or claim information to a third party. This form may not be executed by

any beneficiary recognized as incompetent for VA purposes, nor can VA accept this form from any

beneficiary recognized as incompetent for VA purposes.

(Print clearly)

2. FIRST, MIDDLE, LAST NAME OF BENEFICIARY/CLAIMANT WHO IS NOT THE VETERAN

1. FIRST, MIDDLE, LAST NAME OF VETERAN

(Print clearly)

(No. and Street or rural route, City or P.O., State and ZIP Code)

3. ADDRESS OF BENEFICIARY/CLAIMANT

4. VA FILE NUMBER

5. SOCIAL SECURITY NUMBER

6. CONTACT INFORMATION

(If applicable)

A. DAYTIME PHONE NUMBER

B. CELL PHONE NUMBER

C. E - MAIL ADDRESS

7. I (beneficiary/claimant) authorize the Department of Veterans Affairs (VA) to contact the person or organization listed below for the purposes

of providing the following information pertaining to my VA record. (Check only one box below to tell VA the specific benefit or claim information

you want disclosed.)

Any Information (Go to Item 9)

Limited Information (Go to Item 8)

8. IF YOU SELECTED "LIMITED INFORMATION", CHECK ALL THAT APPLY

Status of pending claim or appeal

Amount of money owed VA

Other

Current benefit and rate

Request a benefit payment letter

Payment history

Change of address or direct deposit

9. IF YOU SELECTED "ANY INFORMATION", THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE:

One time only

From the date of signing below until

(Specify date - month, day, year)

Ongoing until written notice is given to VA to terminate

10. VA IS AUTHORIZED TO DISCLOSE THE INFORMATION AS SPECIFIED ABOVE TO THE PERSON OR ORGANIZATION LISTED BELOW. NOTE: IF

(Please print clearly)

AUTHORIZATION IS FOR AN ORGANIZATION, PLEASE PROVIDE THE FIRST AND LAST NAME OF THE ORGANIZATION'S REPRESENTATIVE.

A. NAME OF PERSON OR ORGANIZATION

B. ADDRESS OF PERSON OR ORGANIZATION

Bluestein, Nichols, Thompson & Delgado, LLC -

PO Box 7965, Columbia, SC 29202

Osborne E. Powell, Jr. & Kenneth H. Dojaquez

11. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY

QUESTION BOX IN 11A AND PROVIDE THE ANSWER IN 11B.

A. SECURITY QUESTION

B. ANSWER

The city and state your mother was born in

The name of the high school you attended

Your first pet's name

Your favorite teacher's name

Your father's middle name

(Do NOT print)

12B. DATE SIGNED

12A. SIGNATURE

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, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify

your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary.

Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless

the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect.

RESPONDENT BURDEN: We need this information to release your private benefit and/or claim information to a designated third party(ies). The execution of this form

does not authorize the release of information other than that specifically described. The information requested on this form will authorize release of the information you

specify. 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

If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions

about this form.

VA FORM

SUPERSEDES VA FORM 21-0845, DEC 2009, WHICH

21-0845

MAY 2010

WILL NOT BE USED.