Va Form 21-22a - Appointment Of Individual As Claimant'S Representative

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OMB Control No. 2900-0321
Respondent Burden: 5 minutes
1. VA FILE NO(S)
Include prefix)
(
APPOINTMENT OF INDIVIDUAL AS CLAIMANT'S REPRESENTATIVE
Note - If you would prefer to have a service organization assist you with your claim, you may use VA Form 21-22,
"Appointment of Veterans Service Organization As Claimant's Representative."
PRIVACY ACT NOTICE: 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. However, failure to respond provide the requested information could impede the recognition of your representative and/or
identification of disclosable records. Except for information protected by 38 U.S.C. 7332, your representative is not prohibited from redisclosing records. 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: We need this information to recognize the individuals appointed by claimants to act on their behalf in the preparation, presentation, and prosecution of claims for
VA benefits (38 U.S.C. 5902, 5903, and 5904) and for those individuals to accept appointment. We will also use the information to verify consent for disclosure of VA records to the appointed
representative (38 U.S.C. 5701(b) and 7332) Title 38, United States Code, allows us to ask for this information. We estimate that claimants and individuals appointed for purposes of
representation will each 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. A Valid OMB control number 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.
(Veteran, guardian, beneficiary, dependent, or next of kin)
2. NAME OF CLAIMANT
(No. and street or rural route, city or P.O., State an
d ZIP
3. ADDRESS OF CLAIMANT
Code)
4. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN
5. SERVICE NUMBERS
6. BRANCH OF SERVICE
AIR FORCE
(Specify
ARMY
NAVY
MARINE CORPS
COAST GUARD
)
OTHER
7A. NAME OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE
7B. INDIVIDUAL IS (check appropriate box)
INDIVIDUAL PROVIDING REPRESENTATION UNDER
SERVICE ORGANIZATION REPRESENTATIVE
ATTORNEY
AGENT
(Specify organization below)
SECTION 14.630
(*See required statement below. Signatures are
required in Items 7C and 7D)
*INDIVIDUALS PROVIDING REPRESENTATION UNDER SECTION 14.630
(Skip to Item 8, if the box for "Individual Providing Representation Under Section 14.630" was not checked in Item 7B)
The appointment of the individual named in Item 7A (the representative) authorizes the individual to represent the claimant named in Item 2 for a particular claim
pursuant to the provisions of 38 CFR 14.630. By our signatures below, we, the representative and the claimant, attest that no compensation will be charged or paid for
the individual named in Item 7A.
7C. SIGNATURE OF REPRESENTATIVE NAMED IN ITEM 7A
7D. SIGNATURE OF CLAIMANT NAMED IN ITEM 2
(No. and street or rural route, city or P.O., State, and ZIP code)
8. ADDRESS OF INDIVIDUAL APPOINTED AS CLAIMANT'S REPRESENTATIVE
(Continued on Reverse)
VA FORM
SUPERSEDES VA FORM 21-22a, MAY 2007,
21-22a
JUN 2009
WHICH WILL NOT BE USED.

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