O. State and ZIP code VA FORM AUG 2015 21-22a SUPERSEDES VA FORM 21-22a JUN 2009 WHICH WILL NOT BE USED. OMB Control No* 2900-0321 Respondent Burden 5 Minutes Expiration Date 08/31/2018 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 www. reginfo. gov/public/do/PRAMain* If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form* 2. NAME OF CLAIMANT Veteran guardian beneficiary dependent or next of kin 3. ADDRESS OF CLAIMANT No* and street or rural route city or P. O. State and ZIP Code 4. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN 5. SERVICE NUMBERS 6. BRANCH OF SERVICE NAVY ARMY AIR FORCE MARINE CORPS COAST GUARD OTHER Specify 7A.
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