WHAT IF I CHANGE MY MIND?
If you change your mind and do not want VA to give out your personal benefit or claim information, you may notify us in writing, or by
telephone at 1-800-827-1000 or contact VA online at ASK VA: https://ask.va.gov. Upon notification from you VA will no longer give out
benefit or claim information (except for the information VA has already given out based on your permission).
GENERAL INFORMATION
INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO
DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY
At VA, we recognize and respect the importance of privacy. Personal information that we collect is kept confidential to the extent
provided by law. In accordance with the Privacy Act and applicable confidentiality statutes, VA will only disclose the information in its
custody or control 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; or where the disclosure is otherwise legally permitted, including release for a
purpose compatible with the purpose for which it was collected.
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WHERE DO I SEND MY COMPLETED WORK?
You should make a copy of your signed authorization for your records before mailing it to VA. You can only have one VA Form
21-0845, Authorization to Disclose Personal Information to a Third Party, on file with VA at a time.
Send your signed authorization in by utilizing the following methods:
By law, VA must have your written permission (an "authorization") to use or give out your claim or benefit information for any purpose
that is not permitted by all applicable legal authorities. You may revoke your written permission at any time, except if VA has already
acted based on your permission.
NOTE:
QUESTIONS SPECIFIC INSTRUCTIONS
1-5
In this section, give us the veteran's identification information to include name, social security number, VA
file number, date of birth and the veteran's service number, if applicable.
6-9 In this section, provide the beneficiary/claimant's identification information, who is not the veteran.
10-13
In Item 10 VA will give your personal benefit or claim information to the person or organization you enter in
this box. You may select only one person or one organization. If you designate an organization, you
must also identify one or more individuals in that organization to whom VA may disclose your benefit or
claim information. This form cannot be used to disclose federal tax information to third parties.
IMPORTANT: The information provided in Item 6, "Name of Beneficiary/Claimant Who Is Not the Veteran,"
cannot be the same information provided in Item 10.
Item 13 tells VA the duration of your consent. If you do not want your authorization to be effective
indefinitely, tell us when to stop releasing your personal benefit or claim information to your authorized third
party in Item 13. Check the box that applies and fill in dates, if applicable.
14
Select the security question you would like us to ask your designated third party and provide the answer.
This question will be asked each time your designated third party contacts the VA.
MAIL TO SUBMIT ONLINE
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
VA gov: www.va.gov
Direct Upload via access.va.gov
VA FORM 21-0845, FEB 2023
SECTION III - CONTACT INFORMATION
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
SECTION II - BENEFICIARY/CLAIMANT'S IDENTIFICATION INFORMATION
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION
TO A THIRD PARTY
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
Use this form if you want to give the Department of Veterans Affairs (VA) permission to release your
personal beneficiary or claim information to a third party. 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.
6. NAME OF BENEFICIARY/CLAIMANT WHO IS NOT THE VETERAN (First, Middle Initial, Last)
7. ADDRESS OF BENEFICIARY/CLAIMANT (Number and Street or rural route, P.O. Box, City, State, ZIP Code and Country)
1. VETERAN'S NAME (First, Middle Initial, Last)
3. VA FILE NUMBER (If known)
SUPERSEDES VA FORM 21-0845, SEP 2016.
You may either complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly to expedite processing
the form.
4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
2. VETERAN'S SOCIAL SECURITY NUMBER
5. VETERAN'S SERVICE NUMBER
(If applicable)
8. TELEPHONE NUMBER (Include Area Code)
9. EMAIL ADDRESS (Optional)
10. VA IS AUTHORIZED TO DISCLOSE THE INFORMATION SPECIFIED BELOW TO ONE PERSON OR ONE ORGANIZATION LISTED BELOW. PROVIDE THE NAME
AND ADDRESS OF THE PERSON YOU HAVE CHOSEN TO RECEIVE INFORMATION FROM VA IN ITEMS 10A AND 10B OR PROVIDE THE NAME AND
ADDRESS OF THE ORGANIZATION YOU HAVE CHOSEN AND THE NAME OF THE ORGANIZATION'S REPRESENTATIVE IN ITEMS 10C AND 10D.
A. NAME OF PERSON (First, Middle Initial, Last Name)
B. ADDRESS OF PERSON
An organization may have more than one representative. Include the first and last name of any additional representatives.
C. NAME OF ORGANIZATION (Include name of representative(s))
Enter International Phone Number (If applicable)
I agree to receive electronic correspondence from VA in regards to my claim.
VA FORM
FEB 2023
21-0845
Page 2
INSTRUCTIONS:
NOTE:
No. &
Street
Apt./Unit Number
State/Province Country ZIP Code/Postal Code
City
No. &
Street
Apt./Unit Number
State/Province Country ZIP Code/Postal Code
City
NOTE:
D. ADDRESS OF ORGANIZATION
No. &
Street
Apt./Unit Number
State/Province Country ZIP Code/Postal Code
City
OMB Approved No. 2900-0736
Respondent Burden: 5 minutes
Expiration Date: 02/28/2026
We need this information to release your private benefit and/or claim information to a designated third party(ies). The execution of this form does not
authorize the release of information other than that specifically described. The information requested on this form will authorize release of the information you specify. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information, and complete this form. VA
cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on
where to send comments or suggestions about this form.
SECTION IV - DECLARATION OF INTENT
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
12. IF YOU SELECTED "LIMITED INFORMATION", CHECK ALL THAT APPLY:
A. SECURITY QUESTION B. ANSWER
16. DATE SIGNED (MM/DD/YYYY)
14. SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE
SECURITY QUESTION BOX IN ITEM 14A AND PROVIDE THE ANSWER IN ITEM 14B.
15. VETERAN/BENEFICIARY/CLAIMANT'S SIGNATURE (REQUIRED)
VA FORM 21-0845, FEB 2023
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VETERAN'S SSN
13. IF YOU SELECTED "ANY INFORMATION", THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE:
11. I, THE VETERAN/BENEFICIARY/CLAIMANT AUTHORIZE VA TO CONTACT THE PERSON OR ORGANIZATION LISTED IN ITEM 10A OR 10C FOR THE
PURPOSE OF PROVIDING THE FOLLOWING INFORMATION PERTAINING TO MY VA RECORD
(Check only one box below to tell VA the specific benefit
or claim information you want disclosed)
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 (Specify below):
One time only Ongoing until written notice is given to VA to terminate
From the date of signing below until (Specify Date (MM/DD/YYYY)):
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
LIMITED INFORMATION (Go to Item 12) ANY INFORMATION (Go to Item 13)
VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or title 38,
Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money
owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and
status, and personnel administration as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA,
published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are
properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will
not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in
effect.
PRIVACY ACT INFORMATION:
RESPONDENT BURDEN:
