Form 21-0845 -Authorization To Disclose Personal Information To A Third Party
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3INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO
DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY
GENERAL INFORMATION
At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept confidential to the
extent provided by law. In accordance with the Privacy Act and applicable confidentiality statutes, VA will only disclose the
information in its custody or control in the following circumstances: where the individual identifies the particular information
and consents to its use; where disclosure of the information is required by law; or where the disclosure is otherwise legally
permitted, including release for a purpose compatible with the purpose for which it was collected.
By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit information for any
purpose that is not permitted by all applicable legal authorities. You may revoke your written permission at any time, except if
VA has already acted based on your permission.
SPECIFIC INSTRUCTIONS
Questions 1 - 5
In this section, give us the veteran's identification information to include name, social security number, VA file number, date
of birth and the veteran's service number, if applicable.
Questions 6 - 9
In this section provide the beneficiary/claimant's identification information.
Questions 10 - 13
This section tells VA the duration of your consent. If you do not want your authorization to be effective indefinitely, tell us
when to stop releasing your personal benefit or claim information to your authorized third party in Item 12. Check the box that
applies and fill in dates, if applicable.
In Item 13 VA will give your personal benefit or claim information to the person or organization you fill in here. You may
select only one person or one organization. If you designate an organization, you must also identify one or more
individuals in that organization to whom VA may disclose your benefit or claim information. This form cannot be used to
disclose federal tax information to third parties.
Important: The information provided in Item 6, "Name of Beneficiary/Claimant Who Is Not the Veteran" cannot be the same
information provided in Item 13.
Question 14
Select the security question you would like us to ask your designated third party and provide the answer. This question will
be asked each time your designated third party contacts our office.
Where Do I Send My Completed Form?
You can obtain the VA mailing address to send your completed, signed authorization by accessing our Internet website
at
or in the government pages of your telephone book under "United States Government,
Veterans."
You should make a copy of your signed authorization for your records before mailing it to VA. You can only have one active
VA Form 21-0845 on file with VA at a time.
WHAT IF I CHANGE MY MIND?
If you change your mind and do not want VA to give out your personal benefit or claim information, you may notify us in
writing, or by telephone at 1-800-827-1000 or electronically via the Internet at https://iris.va.gov. Upon notification from you
VA will no longer give out benefit or claim information (except for the information VA has already given out based on your
permission).
VA FORM
21-0845
PAGE 1
SEP 2016
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