Institution block
To and From boxes and the name and address of the institution at the top of page 1.
21-4193
Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution
- Agency
- VA
- Revision
- December 2025
- Fillable fields
- 47
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-4193: Notice to VA of Veteran or Beneficiary Incarcerated in Penal Institution
VA Form 21-4193 is the U.S. Department of Veterans Affairs Notice to Department of Veterans Affairs of Veteran or Beneficiary Incarcerated in Penal Institution. Its signature section is for an official of the institution. The form's note says that under Title 38, U.S.C., 1505, 3482, 3680 and 5313, awards of VA benefits for veterans and beneficiaries are subject to adjustment or discontinuance while such persons are incarcerated.
The form identifies the Veteran or beneficiary, then records the offense, conviction, confinement, sentence and scheduled release date, and whether the individual is in a work release or halfway house program. Section IV is the institutional official's name, title, signature and the institution's phone number.
The PDF has three pages: the form on pages 1 and 2 and submission information on page 3. 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 21-4193
Section I: identification
Items 2 to 7: the Veteran or beneficiary's name, Social Security number, VA file number, the Veteran's date of birth and service number if applicable, and the relationship to the Veteran if other than the Veteran.
Section II: offense and conviction
The date the offense was committed, the type of offense (felony, misdemeanor or infraction), the date of conviction and the date of confinement following conviction.
Section II: sentence and release
Length of sentence, whether incarceration has lasted or will last more than 60 days following the date of conviction, the scheduled release date, and whether the individual is in a work release or halfway house program, with the date entered.
Section III: remarks
Space for remarks, continued at the top of page 2.
Section IV and notices
The institutional official's name, title, date, signature and institution phone, then the Privacy Act and respondent burden notices, about 15 minutes.
How an institution completes VA Form 21-4193
- 1
Fill in the institution block
Enter the To and From details and the name and address of the institution.
- 2
Identify the Veteran or beneficiary
Complete Section I. By hand, the form asks for ink, neat and legible printing and one letter per box.
- 3
Record the incarceration details
Complete Section II, including Item 13B, the date entered, if the answer to the work release or halfway house question is yes.
- 4
Sign as the institutional official
Enter the official's name and title, the date, the required signature in Item 16 and the institution's phone number.
- 5
Send it to VA
The note on page 1 says to see page 3 for how to submit the form. Page 3 lists electronic submission and mailing addresses.
Why fill Form 21-4193 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
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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
Electronically
Page 3 says documents may be submitted by mail, in person at a VA regional office or electronically, that VA recommends electronic submission as the fastest method, and points to www.va.gov/disability/upload-supporting-evidence and QuickSubmit in AccessVA.
Compensation Benefits
Department of Veterans Affairs, Compensation Intake Center, PO Box 4444, Janesville, WI 53547. Toll Free Phone: 1-800-827-1000. Toll Free Fax: (844) 531-7818.
Pension and Survivors Benefits
Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547. Toll Free Phone: 1-800-827-1000. Toll Free Fax: (844) 655-1604.
Other addresses
Page 3 also lists the Board of Veterans' Appeals and the Fiduciary Intake Center, and says to use the related mailing address.
Edition
The December 2025 edition supersedes the October 2022 edition. It carries OMB Approved No. 2900-0116, which expires 12/31/2028.
Related forms
21-4138
Statement in Support of Claim (VA Form 21-4138)
33 fields, 2 pages
21-526EZ
Application for Disability Compensation and Related Compensation Benefits
345 fields, 15 pages
21P-527EZ
Application for Veterans Pension
477 fields, 17 pages
21P-534EZ
Application for D.I.C., Survivors Pension, and/or Accrued Benefits
626 fields, 20 pages
Who completes VA Form 21-4193?
The form's signature section is for an official of the institution.
Official sources and the blank
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Questions about Form 21-4193
What is VA Form 21-4193?
It is a notice to VA that a Veteran or beneficiary is incarcerated in a penal institution. The form's note says VA benefit awards are subject to adjustment or discontinuance while veterans and beneficiaries are incarcerated.
Who fills out VA Form 21-4193?
Section IV, Signature of Official, is for an official of the institution. It holds the institutional official's name, title and required signature, plus the institution's phone number.
What incarceration details does the form ask for?
The offense date and type, conviction and confinement dates, length of sentence, whether incarceration lasts more than 60 days after conviction, the scheduled release date and any work release or halfway house program.
Where is VA Form 21-4193 sent?
Page 3 lists electronic submission and mailing addresses, including the Compensation Intake Center and the Pension Intake Center in Janesville, WI, and says to use the related mailing address.
Which edition is current?
The December 2025 edition, which supersedes the October 2022 edition. OMB Approved No. 2900-0116 expires 12/31/2028.