Application For Accreditation As A Claims Agent Or Attorney Page 4

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PRIVACY ACT INFORMATION: The information requested on this form is solicited under Section 5904, Title 38, United States Code and Section
14.629(b) of Title 38, Code of Federal Regulations. It will enable VA to determine initial eligibility for accreditation as a claims agent or attorney to
represent claimants before VA. Any information on this form may be disclosed outside VA only if authorized under the Privacy Act, including the
routine uses identified in the VA system of records, 01VA022, Current and Former Accredited Representative, Claims Agent, Attorney, and
Representative, Claims Agent, and Attorney Applicant and Rejected Applicant Records--VA, published in the Federal Register. Routine disclosures
may be made for the following purposes: civil or criminal law enforcement or investigation; congressional communications; communications relevant
to the delivery of VA benefits; verification of identity and status; litigation conducted by the Department of Justice; and communication with
employing entities and governmental licensing organizations concerning information relevant to employment or licensing of a prospective, present, or
former representative, claims agent or attorney. Providing the requested information is voluntary; however, failure to furnish information may delay or
prevent action on the application.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it
displays a valid OMB Control Number. Public reporting burden for this collection of information is estimated to average 45 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. If you have comments regarding this burden estimate or any other aspect of this collection of information
send your comments to VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, D.C. 20420. Please do not send applications for
accreditation to this address.
VA FORM 21a, MAY 2007, PAGE 4

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