Fillable Form VA 21-0845

What is Form VA 21-0845?

Form VA 21-0845, Authorization to Disclose Personal Information to a Third Party, is a legal form issued by the Department of Veterans Affairs (VA) that is used by a veteran to grant permission in releasing their beneficiary or claim information to a third party.

In accordance with the Privacy Act 1974 or title 38, Code of Federal Regulation for routine use, and applicable confidentiality statutes, the VA will only disclose information in the following circumstances:

• Where the individual identifies the particular information and consents to its use
• Where disclosure of the information is required by law
• Where the disclosure is otherwise legally permitted, including a release for a purpose compatible with the purpose for which it was collected.

How to fill out Form VA 21-0845?

Form VA 21-0845 is a two-page document. Do not leave the required items blank to avoid any problems with your request.

Note: This form may not be executed by any beneficiary recognized as incompetent for VA purposes, nor can VA accept this form from any beneficiary recognized as incompetent for VA purposes.

Page 1 of 2

SECTION I - VETERAN’S IDENTIFICATION INFORMATION

• Name of Veteran

Enter the full legal name of the veteran in the following format: First Name, Middle Initial, and Last Name.

• Veteran’s Social Security Number

Enter the Social Security Number of the veteran.

• VA File Number

Enter the VA file number of the veteran.

• Veteran’s Date of Birth

Enter the veteran’s birthdate in the following format: Month, Day, and Year.

• Veteran’s Service Number

Enter the service number of the veteran if applicable.

SECTION II - BENEFICIARY/CLAIMANT’S IDENTIFICATION INFORMATION

• Name of Beneficiary/Claimant Who Is Not the Veteran

Enter the full legal name of the beneficiary or claimant in the following format: First Name, Middle Initial, and Last Name.

• Address of Beneficiary/Claimant

Enter the complete address of the beneficiary or claimant including the Number and Street or Rural Route, P.O. Box, Apartment or Unit Number, City, State or Province, Country, and ZIP or Postal Code.

• Preferred Phone Number

Enter the beneficiary or claimant’s preferred phone number including the area code.

• Preferred Email Address

Enter the beneficiary or claimant’s preferred email address.

This is optional.

SECTION III - CONTACT INFORMATION

For item 10, the beneficiary or claimant is authorizing the VA to contact the person or organization listed in this form to provide the following information pertaining to their VA record.

Mark the appropriate box to determine the specific benefit or claim information you want to disclose to the VA. You may select:

• Any Information
• Limited Information

If you selected the first option, proceed to item number 12.

If you selected the second option, proceed to item number 11.

For item 11, mark all the appropriate boxes that apply to determine the limited information you want to be disclosed. You may select:

• Status of pending claim or appeal
• Current benefit and rate
• Payment history
• Amount of money owed VA
• Request a benefit payment letter
• Change of address or direct deposit
• Other

If you selected the last option, enter specific details.

For item 12, mark the appropriate box to determine the terms of release of information if you don’t want your authorization to be effective indefinitely. You may select:

• One time only
• Ongoing until written notice is given to VA to terminate
• From the date of signing below until:

If you selected the last option, enter a specific date in the following format: Month, Day, and Year.

For item 13, the VA will give your claim information to the person or organization you fill in here.

• Name of Person or Organization

Enter the full legal name of the authorized person or organization.

If authorization is for an organization, enter the first and last name of the organization’s representative.

• Address of Person or Organization.

Enter the complete address of the authorized person or organization.

Do not enter the information you provided in Item 6, Name of Beneficiary/Claimant Who Is Not the Veteran. The information in Item 6 can’t have the same information as Item 13.

This form can’t be used to disclose federal tax information to third parties.

Page 2 of 2

Veteran’s SSN

Enter the Social Security Number of the veteran.

For item 14, mark the appropriate box to determine the security question you want to use when verifying the identity of your designated third party. You may select:

• The city and state your mother was born in
• The name of the high school you attended
• Your first pet’s name
• Your favorite teacher’s name
• Your father’s middle name

Select only one security question.

After selecting your preferred security question, enter the corresponding answer in 14B.

The security question you selected will be asked each time your designated third party contacts the VA office.

SECTION IV - DECLARATION OF INTENT

This section indicates that you certify the statements on this form are true and correct to the best of your knowledge and belief.

15A. Signature

Affix your signature

Do not print.

15B. Date Signed

Enter the date when you signed this form.

Where to submit Form VA 21-0845?

You can submit the completed Form VA 21-0845 and any supporting materials via mail or fax.

Mail to:

Department of Veterans Affairs

Evidence Intake Center

P.O. Box 4444

Janesville, WI 53547-4444

Fax to:

844-531-7818 (Toll-Free) or Local: 248-524-4260

Tips:

• The applicant should not forget to sign this form to make it valid.
• Before submitting this form, make sure that you have a copy of your signed authorization for your records. You can only have one active Form VA 21-085 on file with VA at a time.
• If you changed your mind and refused to give out your personal benefit or claim information to another person or organization, notify the Department of Veterans Affairs immediately. The VA can revoke your written permission at any time except the information they have already given out based on your permission.
• For other concerns about Form VA 21-0845, go to the official website of the Department of Veterans Affairs or contact them by telephone at 1-800-827-1000.