Form 21-0845 -Authorization To Disclose Personal Information To A Third Party Page 2

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OMB Approved No. 2900-0736

Respondent Burden: 5 minutes

Expiration Date: 09/30/2019

(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.

SECTION I - VETERAN'S IDENTIFICATION INFORMATION

NOTE: You can either complete the form online or by hand. Please print the information requested in ink, neatly, and legibly to help process the form.

(First, Middle Initial, Last)

1. NAME OF VETERAN

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

Month

Day

Year

5. VETERAN'S SERVICE NUMBER (If applicable)

SECTION II - BENEFICIARY/CLAIMANT'S IDENTIFICATION INFORMATION

(First, Middle Initial, Last)

6. NAME OF BENEFICIARY/CLAIMANT WHO IS NOT THE VETERAN

(Number and Street or rural route, P.O. Box, City, State, ZIP Code and Country)

7. ADDRESS OF BENEFICIARY/CLAIMANT

No. &

Street

Apt./Unit Number

City

Country

State/Province

ZIP Code/Postal Code

(Optional)

8. PREFERRED PHONE NUMBER (Include Area Code)

9. PREFERRED EMAIL ADDRESS

SECTION III - CONTACT INFORMATION

10. 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 12)

Limited Information (Go to Item 11)

11. 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

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