The VBA VA 21 4138 form is a document used by veterans to request a review of their disability claims. This form helps ensure that veterans receive the benefits they deserve by allowing them to appeal decisions made by the Department of Veterans Affairs. If you need to fill out this form, click the button below for assistance.
The VBA VA 21 4138 form plays a crucial role in the process of applying for benefits from the U.S. Department of Veterans Affairs (VA). This form is specifically designed for veterans seeking to establish their eligibility for compensation due to service-related disabilities. Completing the form accurately is essential, as it serves as a formal request for the VA to assess the veteran's condition and determine the appropriate level of benefits. Information required on the form includes personal details, service history, and specifics about the disability or medical condition in question. Additionally, the form may require supporting documentation, which helps substantiate the claims made by the veteran. Understanding the importance of the VBA VA 21 4138 form can significantly impact the outcome of a veteran's benefits application, making it imperative for applicants to approach the process with care and attention to detail.
OMB Control No. 2900-0075 Respondent Burden: 15 minutes Expiration Date: 07/31/2027
STATEMENT IN SUPPORT OF CLAIM
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. Use this form to
submit a statement to support a claim. For more information you can contact us through Ask VA: https://ask.va.gov/, or call us toll-free at 1-800-827-1000 (TTY:711). VA forms are available at www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
SECTION I: VETERAN/BENEFICIARY'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and insert one letter per box to help expedite processing of the form.
1. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VA FILE NUMBER (If applicable)
4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
5. VETERAN'S SERVICE NUMBER (If applicable)
6. TELEPHONE NUMBER (Include Area Code)
7. E-MAIL ADDRESS (Optional)
Enter International Phone Number (If applicable)
8. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province
Country
City
ZIP Code/Postal Code
SECTION II: REMARKS
(The following statement is made in connection with a claim for benefits in the case of the above-named veteran/beneficiary)
VA FORM
21-4138
SUPERSEDES VA FORM 21-4138, JUN 2021.
Page 1
JUL 2024
VETERAN'S SOCIAL SECURITY NO.
SECTION II: REMARKS (Continued)
SECTION III: DECLARATION OF INTENT
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
9. SIGNATURE OF VETERAN/BENEFICIARY (Required)
10. DATE SIGNED (MM/DD/YYYY)
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.
PRIVACY ACT INFORMATION: The 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 Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. 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: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control Number. The OMB control number for this project is 2900-0075, and it expires 07/31/2027. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0075 in any correspondence. Do not send your completed VA Form 21-4138 to this email address.
VA FORM 21-4138, JUL 2024
Page 2
Filling out the VBA VA 21 4138 form is a straightforward process. Make sure to have all necessary information at hand before you begin. This form is essential for your next steps, so accuracy is key. Follow these instructions carefully to ensure everything is completed correctly.
What is the VBA VA 21 4138 form?
The VBA VA 21 4138 form, also known as the "Request for Employment Information in Connection with Claim for Disability Benefits," is used by veterans to request information regarding their employment history. This form is essential for veterans seeking disability benefits, as it helps the Department of Veterans Affairs (VA) assess the impact of service-related injuries or conditions on a veteran's ability to work.
Who should fill out the VBA VA 21 4138 form?
This form is intended for veterans who are applying for disability benefits and need to provide detailed information about their employment history. If you have experienced difficulties in maintaining employment due to a service-related condition, completing this form can help support your claim. It’s important for veterans who have been employed or have had a significant work history to provide accurate information.
How do I complete the VBA VA 21 4138 form?
To complete the VBA VA 21 4138 form, you will need to provide personal information such as your name, Social Security number, and service details. You will also be asked to list your employment history, including the names of employers, job titles, and dates of employment. Be thorough and accurate, as this information will be used to evaluate your claim. If you're unsure about any section, consider reaching out to a veteran service organization for assistance.
Where do I submit the VBA VA 21 4138 form?
You can submit the VBA VA 21 4138 form to your local VA regional office. It's important to ensure that you send it to the correct office, as this can expedite the processing of your claim. You may also have the option to submit the form online through the VA’s eBenefits portal, which can make the process more convenient.
What happens after I submit the VBA VA 21 4138 form?
Once you submit the VBA VA 21 4138 form, the VA will review the information provided as part of your disability claim. This process may take some time, as the VA will need to verify the details and may request additional documentation. You can check the status of your claim online or by contacting your local VA office. Stay proactive and keep records of all communications related to your claim to ensure a smoother process.
Filling out the VBA VA 21 4138 form can be a daunting task, and mistakes are all too common. One frequent error is not providing complete personal information. It's crucial to include your full name, address, and contact details. Omitting any of these can lead to delays in processing your claim.
Another mistake involves the failure to sign and date the form. This step might seem minor, but without your signature, the form is considered incomplete. Always double-check to ensure that you’ve signed and dated the document before submission.
Many individuals also overlook the importance of being specific about their claims. Vague descriptions can lead to misunderstandings and may result in a denial of benefits. It’s essential to clearly outline the reasons for your claim, providing as much detail as possible.
Inaccurate information is another common pitfall. Double-check all entries for accuracy. Errors in dates, social security numbers, or service information can cause significant delays and complications in the claims process.
People often forget to include supporting documents. The VBA VA 21 4138 form requires various attachments, such as medical records or service documents. Failing to include these can lead to a denial or a request for additional information, which can slow down the process.
Additionally, some applicants neglect to keep a copy of the submitted form. This oversight can be problematic if there are questions or issues later on. Always make a copy for your records to ensure you have a reference point.
Finally, many individuals fail to follow up on their claims after submission. It’s important to check the status of your claim periodically. This proactive approach can help identify any issues early on and ensure that your claim is processed in a timely manner.
The VBA VA 21 4138 form is a crucial document used by veterans to report their experiences and the impact of their disabilities. However, several other forms and documents often accompany this form to provide additional context or support for a veteran's claim. Below is a list of these documents, each serving a specific purpose in the claims process.
Each of these documents plays a vital role in the claims process for veterans. Together, they help ensure that veterans receive the benefits they deserve based on their service and the challenges they face due to their disabilities.
The VBA VA 21 4138 form is a document used by veterans to report their financial status, which can influence their eligibility for various benefits. Several other forms share similar purposes or functions. Below is a list of documents that are comparable to the VBA VA 21 4138 form, along with explanations of their similarities.
Each of these forms plays a crucial role in the benefits process for veterans and requires a level of financial disclosure that aligns with the intent of the VBA VA 21 4138. Understanding these documents can help veterans navigate their benefits more effectively.
When filling out the VBA VA 21 4138 form, it is important to follow certain guidelines to ensure your application is processed smoothly. Here are six things you should and shouldn't do:
The VBA VA 21 4138 form, also known as the "Request for Higher-Level Review," is often misunderstood. Below are some common misconceptions regarding this form, along with clarifications to help individuals navigate the process more effectively.
While many believe that the VA 21 4138 form is exclusively for those whose claims have been denied, it can also be used by veterans seeking a review of decisions that they believe were made in error, even if their claims were partially granted.
Submitting the VA 21 4138 form does not ensure that the decision will change. The review process involves a thorough examination of the case, and the outcome depends on the merits of the appeal.
While there are time limits for filing a request for a higher-level review, veterans have up to one year from the date of the decision to submit the form. This allows time for careful consideration and preparation of the case.
Many individuals feel intimidated by the form, but it is designed to be straightforward. Clear instructions are provided, and assistance is available through various veteran service organizations if needed.
When filling out the VBA VA 21 4138 form, it is essential to keep several key points in mind to ensure a smooth process.