OMB Control No. 2900-0321
Respondent Burden: 5 Minutes
Expiration Date: 08/31/2018
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.
1. LAST-FIRST-MIDDLE NAME OF VETERAN
2. VA FILE NUMBER (Include prefix)
3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)
National Association of County Veterans Service Officers (NACVSO) Cumberland County, NJ
(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)
Diana M Pitman, RN, BSN, VSO - Cumberland County Department of Veterans Affairs
3322 College Dr.,Office 228, PO Box 1500, Vineland, NJ 08362-1500
3C. E-MAIL ADDRESS OF THE ORGANIZATION NAMED IN ITEM 3A
INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES
4. SOCIAL SECURITY NUMBER (OR SERVICE NUMBER, IF NO SSN)
5. INSURANCE NUMBER(S) (Include letter prefix)
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)
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:
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
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
REVOKED (Reason and date)
COPY OF VA FORM 21-22 SENT TO:
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.
SUPERSEDES VA FORM 21-22, OCT 2014,
WHICH WILL NOT BE USED.