Section I: Veteran's identification
Items 1 to 9 ask for the Veteran's name, Social Security number, VA file number, date of birth, service number, branch of service, mailing address, telephone and an optional email.
21-22a
Appointment of Individual As Claimant’s Representative
- Agency
- VA
- Revision
- July 2023
- Fillable fields
- 90
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-22a: Appointment of Individual As Claimant's Representative
VA Form 21-22a is the U.S. Department of Veterans Affairs Appointment of Individual As Claimant's Representative. VA's form page says that if you want to have an individual help you with your claim or benefits, that person completes and submits this form. The form appoints the individual named in Item 16A to prepare, present and prosecute the claimant's claims for VA benefits based on the service of the Veteran named in Item 1.
The PDF has three pages: Sections I to IV, the conditions of appointment with the signatures, and the mailing addresses. The form points to the VA Office of General Counsel list of accredited attorneys, claims agents and VSO representatives at https://www.va.gov/ogc/apps/accreditation/index.asp, and recommends using it to confirm accreditation before signing any contract or appointing someone. To have a Veterans Service Organization help instead of an individual, the form points to VA Form 21-22.
VA's page says the form can also be filled out online. 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 21-22a
Section II: Claimant's information
Items 10 to 15, if other than the veteran: name, date of birth, relationship to the Veteran, mailing address, telephone and an optional email.
Section III: Appointed representative
Items 16A to 16E ask for the representative's name, type, address, telephone and an optional email. Items 17 and 18 hold the signatures for representation under section 14.630.
Section IV: Authorization information
Item 19 covers disclosure to affiliated personnel, Item 20 access to records on drug abuse, alcoholism or alcohol abuse, HIV or sickle cell anemia, Item 21 limits on that consent, and Item 22 authority to change the claimant's address.
Conditions of appointment and signatures
The appointment terms, the claimant's required signature in Item 23A, limitations on representation for agents or attorneys in Item 24, and the representative's required signature in Item 25A.
Fees, penalty and mailing addresses
Page 3 notes that Section 5904, Title 38, United States Code, contains provisions regarding fees for agents or attorneys, states the penalty for false statements and lists four mailing addresses by type of claim.
How to file VA Form 21-22a
- 1
Check accreditation
The form recommends using the VA Office of General Counsel list to confirm and validate VA accreditation before signing any contract or appointing someone.
- 2
Fill in Sections I and II
Enter the Veteran's details, and the claimant's if other than the veteran. If completed by hand, the form asks for ink, neat and legible printing, one letter per box and fully filled check boxes.
- 3
Enter the representative
Complete Items 16A to 16E and check the type in Item 16B. For representation under section 14.630, Items 17A and 18A are signed.
- 4
Choose the authorizations
Complete Section IV. The form says that unless the boxes in Items 20 and 22 are checked, the claimant does not authorize VA to disclose the protected records, or the representative to change the claimant's address.
- 5
Sign the conditions of appointment
The Veteran or claimant signs Item 23A and the representative signs Item 25A, both marked required. An agent or attorney may enter limitations in Item 24.
- 6
Send it to VA
The form says documents may be submitted by mail, in person at a VA regional office or electronically, and that VA recommends electronic submission as the fastest method. VA's page says the form can be filled out online.
Why fill Form 21-22a 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
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- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it
Compensation claims
Department of Veterans Affairs, Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444.
Pension and survivors benefit claims
Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365.
Fiduciary
Department of Veterans Affairs, Fiduciary Intake, PO Box 95211, Lakeland, FL 33804-5211.
Board of Veterans' Appeals
Department of Veterans Affairs, Board of Veterans' Appeals, PO Box 27063, Washington, DC 20038.
Electronic submission
The form points to www.va.gov/disability/upload-supporting-evidence and to Direct Upload at access.va.gov. VA's form page says you can fill out the form online instead of a paper form.
Edition and questions
The JUL 2023 edition supersedes the FEB 2019 edition. It carries OMB Control No. 2900-0321 with an expiration date printed as 07/31/2026. For questions the form lists Ask VA at https://ask.va.gov/ and 800-827-1000 (TTY:711).
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Who uses VA Form 21-22a?
The form is signed by the Veteran or claimant who makes the appointment and by the individual appointed.
Official sources and the blank
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Questions about Form 21-22a
What is the difference between VA Form 21-22a and VA Form 21-22?
VA Form 21-22a appoints an individual. The form says that to have a Veterans Service Organization assist instead, complete VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative.
Who fills out VA Form 21-22a?
VA's form page says the individual who will help with your claim or benefits completes and submits it. The Veteran or claimant signs Item 23A and the representative signs Item 25A.
How can I check that a representative is accredited?
The form points to the VA Office of General Counsel list at https://www.va.gov/ogc/apps/accreditation/index.asp, searchable by name, state or zip code.
Does it replace an earlier power of attorney?
Item 24 says that unless limited by an agent or attorney, this power of attorney revokes all previously existing powers of attorney.
Can the representative see records about drug or alcohol treatment, HIV or sickle cell anemia?
The form says that unless the box in Item 20 is checked, the claimant does not authorize VA to disclose those records to the representative. Item 21 can limit that consent.
Does the form mention fees?
It says Section 5904, Title 38, United States Code, contains provisions regarding fees for services of agents or attorneys. Individuals representing under section 14.630 attest that no compensation will be charged or paid. The form does not list amounts.
Where do I send VA Form 21-22a?
Page 3 lists separate mailing addresses for compensation claims, pension and survivors benefit claims, fiduciary matters and the Board of Veterans' Appeals. The form says VA recommends electronic submission as the fastest method.