Pages 1 and 2: attachment
Explains when to use the form, which claim form goes with it, the kinds of evidence VA can use, where to get help and the mailing address.
21-0781
Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s)
- Agency
- VA
- Revision
- March 2024
- Fillable fields
- 124
- Pages
- 7
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-0781: Statement in Support of Claimed Mental Health Disorders
VA Form 21-0781 is the U.S. Department of Veterans Affairs Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s). VA's form page describes it for someone diagnosed with a mental health condition related to a traumatic event during military service who wants to apply for related benefits or services. The form says it is optional and not required, and that VA can use the information to review military records and other sources for evidence.
The form groups events into four types: combat traumatic events, personal traumatic events not involving military sexual trauma (MST), personal traumatic events involving MST, and other traumatic events. It says completing every section is helpful but not required, and that approximate dates and locations are acceptable.
The form goes with a claim rather than replacing one: it names VA Form 21-526EZ for a new or increased claim and VA Form 20-0995 for a supplemental claim. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21-0781
Sections I and II: identification and events
Name, Social Security number, VA file number, date of birth, service number and contact details. Item 8 asks the type of event, and Items 9A to 9C give room for up to six events with a brief description, location and date.
Section III: additional information
Item 10 lists behavioral changes after a personal traumatic event that can be checked, Item 11 asks whether an official report was filed and its type, and Item 12 lists possible sources of evidence.
Section IV: treatment information
Item 13 asks whether treatment was received related to the event and where: a private provider, a VA medical center or clinic, a Vet Center, community care or a military treatment facility, with names and approximate dates.
Sections V and VI: remarks and VHA notice
Item 14 is an optional remarks space. Item 15, for MST-related claims, records whether VBA may notify VHA about scheduled exams, Board hearings and decision notices.
Sections VII to X: signatures
The certification with signature and date in Items 16A and 16B, two witnesses if signed with an X, and places for an alternate signer or a power of attorney.
How to file VA Form 21-0781
- 1
Read the attachment pages
The first two pages explain the event types, the claim form that goes with this statement, and the evidence VA can use to support a claim.
- 2
Pair it with a claim form
The form says that, whether or not this statement is completed, a claim form is submitted: VA Form 21-526EZ for a new claim or a claim for increased disability, or VA Form 20-0995 for a supplemental claim.
- 3
Describe each event briefly
Items 9A to 9C ask for a short description, location and date of each event. The form says approximate dates are acceptable, names of others are not required, and VA will not contact anyone named.
- 4
Complete the sections that apply
The form says completing all applicable sections is helpful but not required. It says Item 10 can be skipped when the event is combat only, and that Section V can be left blank.
- 5
Add supporting forms if wanted
The form names VA Form 21-10210 for a lay or witness statement, and VA Form 21-4142 with VA Form 21-4142a for VA to request private provider or Vet Center records.
- 6
Sign, date and send it
Sign Item 16A and date Item 16B, then mail it to the Evidence Intake Center in Janesville, Wisconsin, or apply online at va.gov, where supporting documents can be uploaded.
Why fill Form 21-0781 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and what happens next
By mail
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Online
The form says you can apply online at va.gov, where signing in lets VA prefill parts of the application, save work in progress and accept uploaded supporting documents.
Records VA can get
The form says VA has access to VA medical center, community-based outpatient clinic and military treatment facility records without a consent form. Private provider and Vet Center records need VA Form 21-4142 and VA Form 21-4142a.
Questions about the claim
The form lists 1-800-698-2411, accredited Veterans Service Officers, State Departments of Veterans Affairs and, for MST-related claims, VBA MST Outreach Coordinators.
Veterans Crisis Line
The form lists the Veterans Crisis Line for anyone in crisis: call 988 and then press 1, chat at veteranscrisisline.net, or text 838255, 24 hours a day, 7 days a week.
Related forms
21-526EZ
Application for Disability Compensation and Related Compensation Benefits
345 fields, 15 pages
20-0995
Decision Review Request: Supplemental Claim
136 fields, 7 pages
21-4142
Authorization to Disclose Information to the Department of Veterans Affairs (VA) (VA Form 21-4142)
140 fields, 5 pages
21-10210
Lay/Witness Statement (VA Form 21-10210)
76 fields, 3 pages
21-4142a
General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA form 21-4142a)
96 fields, 2 pages
21-22
Appointment of Veterans Service Organization as Claimant’s Representative
63 fields, 4 pages
Who uses VA Form 21-0781?
VA's form page and the form itself describe these situations.
Official sources and the blank
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Questions about Form 21-0781
Is VA Form 21-0781 required?
The form says it is optional and not required, and that completing it could assist with a claim. VA's page says VA uses the information to help identify records and other evidence.
Is it needed if I apply online with VA Form 21-526EZ?
VA's page says that if you answer the optional mental health questions in the online VA Form 21-526EZ, you do not also need to submit VA Form 21-0781.
Which events does the form cover?
Item 8 lists four types: combat traumatic events, personal traumatic events not involving MST, personal traumatic events involving MST, and other traumatic events. The form says more than one box can be checked.
Are exact dates and places needed?
The form says approximate dates and locations are acceptable, and that VA will still review and consider all available evidence if this information cannot be included.
Will VA contact people named on the form?
The form says that if you name other people who were involved or present, VA will not contact them, and that providing names is not required.
What is Section VI for?
Section VI applies only when personal traumatic events involving MST are checked in Item 8. It records whether VBA may notify VHA about scheduled exams, Board hearings and decision notices. The form says this choice does not affect the status or outcome of the claim.
Where do I mail VA Form 21-0781?
The form lists Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. It also says you can apply online at va.gov.