Department Of Veterans Affairs Report Of Contact
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1Department of Veterans Affairs
VA OFFICE
IDENTIFICATION NOS., (C, XC, SS, XSS, V, K, etc.)
REPORT OF CONTACT
«ROStationNumbe
«ClaimPayee»
(NOTE: This form must be filled out in ink or on typewriter,
as it becomes a permanent record in veterans’ folders.)
r»
LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)
DATE OF CONTACT
«FullName»
«CurrentDate»
ADDRESS OF VETERAN
TELEPHONE NO. OF VETERAN (Include Area Code)
«MailingAddress»
Home: «HomePhone»
Work: «WorkPhone»
PERSON CONTACTED
TYPE OF CONTACT (Check)
PERSONAL
TELEPHONE
ADDRESS OF PERSON CONTACTED
TELEPHONE NO. OF PERSON CONTACTED (Include
Area Code)
BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN
DIVISION OR SECTION
EXECUTED BY (Signature and title)
VR&C DIVISION
VA FORM 119
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