Va Form 21-22 - Appointment Of Veterans Service Organization As Claimant'S Representative

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OMB Control No. 2900-0321

Respondent Burden: 5 minutes

APPOINTMENT OF VETERANS SERVICE ORGANIZATION

AS CLAIMANT'S REPRESENTATIVE

NOTE - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, "Appointment of Individual as Claimant's

Representative." VA Forms are available at

IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM.

2. VA FILE NUMBER (Include prefix)

1. LAST-FIRST-MIDDLE NAME OF VETERAN

3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)

(This is an appointment of the entire

3B. NAME AND JOB TITLE OF OFFICIAL REPRESENTATIVE ACTING ON BEHALF OF THE ORGANIZATION NAMED IN ITEM 3A

organization and does not indicate the designation of only this specific individual to act on behalf of the organization)

3C. E-MAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 3A

INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES

5. INSURANCE NUMBER(S) (Include letter prefix)

4. SOCIAL SECURITY NUMBER (OR SERVICE NUMBER, IF NO SSN)

6. NAME OF CLAIMANT (If other than veteran)

7. RELATIONSHIP TO VETERAN

8. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)

9. CLAIMANT'S TELEPHONE NUMBERS (Include Area Code)

A. DAYTIME

B. EVENING

10. E-MAIL ADDRESS (If applicable)

11. DATE OF THIS APPOINTMENT

12. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C.

By checking the box below I authorize VA to disclose to the service organization named on this appointment form any records that may be in my file relating to

treatment for drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia.

I authorize the VA facility having custody of my VA claimant records to disclose to the service organization named in Item 3A all treatment records relating to

drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia. Redisclosure of these records by my

service organization representative, other than to VA or the Court of Appeals for Veterans Claims, is not authorized without my further written consent. This

authorization will remain in effect until the earlier of the following events: (1) I revoke this authorization by filing a written revocation with VA; or (2) I revoke

the appointment of the service organization named above, either by explicit revocation or the appointment of another representative.

13. LIMITATION OF CONSENT - I authorize disclosure of records related to treatment for all conditions listed in Item 12 except:

DRUG ABUSE

INFECTION WITH THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)

ALCOHOLISM OR ALCOHOL ABUSE

SICKLE CELL ANEMIA

14. AUTHORIZATION TO CHANGE CLAIMANT'S ADDRESS - By checking the box below, I authorize the organization named in Item 3A to act on my behalf

to change my address in my VA records.

I authorize any official representative of the organization named in Item 3A to act on my behalf to change my address in my VA records. This authorization does

not extend to any other organization without my further written consent. This authorization will remain in effect until the earlier of the following events: (1) I file a

written revocation with VA; or (2) I appoint another representative, or (3) I have been determined unable to manage my financial affairs and the individual or

organization named in Item 3A is not my appointed fiduciary.

I, the claimant named in Items 1 or 6, hereby appoint the service organization named in Item 3A as my representative to prepare, present and prosecute my claim(s) for

any and all benefits from the Department of Veterans Affairs (VA) based on the service of the veteran named in Item 1. I authorize VA to release any and all of my

records, to include disclosure of my Federal tax information (other than as provided in Items 12 and 13), to my appointed service organization. I understand that my

appointed representative will not charge any fee or compensation for service rendered pursuant to this appointment. I understand that the service organization I have

appointed as my representative may revoke this appointment at any time, subject to 38 CFR 20.608. Additionally, in some cases a veteran's income is developed

because a match with the Internal Revenue Service necessitated income verification. In such cases, the assignment of the service organization as the veteran's

representative is valid for only five years from the date the claimant signs this form for purposes restricted to the verification match. Signed and accepted subject to the

foregoing conditions.

THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC

15. SIGNATURE OF VETERAN OR CLAIMANT (Do Not Print)

16. DATE SIGNED

17. SIGNATURE OF VETERANS SERVICE ORGANIZATION REPRESENTATIVE NAMED IN ITEM 3B (Do Not Print)

18. DATE SIGNED

ACKNOWLEDGED

REVOKED (Reason and date)

COPY OF VA FORM 21-22 SENT TO:

DATE SENT

(Date)

VR&E FILE

EDU FILE

USE

ONLY

LG FILE

INSURANCE FILE

NOTE: As long as this appointment is in effect, the organization named herein will be recognized as the sole representative for preparation, presentation and

prosecution of your claim before the Department of Veterans Affairs in connection with your claim or any portion thereof.

VA FORM

21-22

SUPERSEDES VA FORM 21-22, JUN 2014,

OCT 2014

WHICH WILL NOT BE USED.