21-10210
Lay/Witness Statement (VA Form 21-10210)
VA Form 21-10210 is the U.S. Department of Veterans Affairs Lay/Witness Statement. VA's form page says to use it to submit a formal statement to support your VA claim, or the claim of another Veteran or eligible family member, and that people also sometimes call this statement a buddy statement. The form's instructions say it is used to submit a statement as a veteran/claimant or someone writing on your behalf to support a claim.
The PDF has three pages. Sections I and II identify the Veteran and, when different, the claimant. Section III holds the statement over pages 2 and 3, Section IV is the witness contact information and Section V is the certification and signature. The form says to use a separate VA Form 21-10210 for each statement.
VA's page says the statement can also be submitted online. You can fill out the PDF free in your browser on this page and download the result without an account.
Items 1 to 8 ask for the Veteran's name, Social Security number, VA file number and VA insurance file number if applicable, date of birth, mailing address, telephone and email, with a box to agree to electronic correspondence.
Items 9 to 16 repeat the same details for the claimant, completed only if the claimant is not the veteran.
Item 17 spans pages 2 and 3. The form asks you to indicate the claimed issue you are addressing and to describe what you yourself know or have observed about the facts or circumstances relevant to the claim.
Items 18 to 21 ask for the witness's name, relationship to the veteran/claimant, telephone and email.
A certification that the statement is true and correct to the best of your knowledge and belief, the required signature of the veteran, claimant or witness in Item 22A and the date in Item 22B.
Page 3 states the penalty for willfully submitting a false statement, the Privacy Act notice and a respondent burden of 10 minutes.
The instructions say to read the Privacy Act and Respondent Burden on page 3 before completing the form.
Enter the Veteran's details, and Section II only if the claimant is not the veteran. If completed by hand, the form asks for ink, neat and legible printing, one letter per box and fully filled circles.
In Item 17, name the claimed issue and describe what the writer knows or has observed. The statement continues on page 3.
If someone else is writing on your behalf, complete Section IV with the witness's name, relationship and contact details.
The veteran, claimant or witness signs Item 22A, which the form marks as required, and enters the date in Item 22B.
Mail it to the Evidence Intake Center in Janesville, Wisconsin, or submit the statement online through VA's form page. The instructions say to submit it with your application when providing additional statements to support a claim.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
VA's form page says you can submit your statement online instead of sending the paper form.
The form points to Ask VA at https://ask.va.gov/ and the toll-free number 1-800-827-1000 (TTY:711).
The PDF is the JUL 2024 edition, which supersedes the JUN 2021 edition. VA's form page lists a revision date of June 2021. The PDF carries OMB Approved No. 2900-0881, which expires 07/31/2027.
21-4138
33 fields, 2 pages
21-0781
124 fields, 7 pages
21-526EZ
345 fields, 15 pages
21-0966
49 fields, 2 pages
20-0995
136 fields, 7 pages
21-4142
140 fields, 5 pages
The form's instructions and section notes describe who writes the statement and who fills in which parts.
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VA's form page says people also sometimes call this statement a buddy statement. It is a formal statement to support your VA claim or the claim of another Veteran or eligible family member.
The instructions say the form is used to submit a statement as a veteran/claimant or someone writing on your behalf to support a claim.
Item 17 says to describe what you yourself know or have observed about the facts or circumstances relevant to the claim, and the form asks you to indicate the claimed issue you are addressing.
No. The form says to use a separate VA Form 21-10210 for each statement, including when more than one witness is writing on your behalf.
The form says to complete Sections IV and V if the statement in Section III is from someone else writing on your behalf.
Yes. VA's form page says you can submit your statement online instead of sending the paper form.
The form lists Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
