PHOTO BY LAUREN GO GOLDMAN/VFW $10.2 BILL No. 2900-0321 OMB Control Burden: 5 minutes Respondent 02/28/2022 Expiration Date: VFW RECOVERS MORE THAN (DO NOT WRITE VA DATE STAMP SPACE) IN THIS : Please read IMPORTANT form. completing the VA Form 21-22a, and Respondent please complete center address organization, intake the Privacy Act veterans service form to the appropriate instead of a or fax this your claim you can mail assist you with When completed an individual prefer to have s. t's Representative. of the form. NOTE: If you Individual as Claiman www.va.gov/vaform processing at INFORMATION of expedite to are available Appointment VETERAN'S and legibly 4. VA forms ink, neatly, SECTION I: requested in shown on Page If or by hand. the form online can either complete Last) NOTE : You Middle Initial, NAME (First, 1. VETERAN'S SOCIAL SECURITY NUMBER (SSN) completed by hand, print the information OF VETERANS REPRESENTATIVE Page 3 before APPOINTMENT on AS CLAIMANT'S Burden Information SERVICE ORGANIZATION 3. VA FILE NUMBER (If applicable) 4. VETERAN'S Month DATE OF BIRTH Day Year 2. VETERAN'S 6. INSURANCE 5. VETERAN'S SERVICE NUMBER (If applicable) street or rural route, P.O. Box, NUMBER(S) (If applicable) (Include letter prefix) City, State, ZIP Code and Country) 7. VETERAN'S No. & Street MAILING ADDRESS (Number and City ZIP Code/Postal Country Area Code) 9. VETERAN'S Code (Optional) Apt./Unit Number State/Province 8. VETERAN'S TELEPHONE EMAIL ADDRESS NUMBER (Include SECTION II: 10. CLAIMANT'S NAME Initial, (First, Middle Last) CLAIMANT'S INFORMATION (If other than veteran) 11. CLAIMANT'S No. & Street MAILING ADDRESS (Number rural and street or route, P.O. Box, City, State, ZIP Code and Country) City ZIP Code/Postal Country Area Code) 13. CLAIMANT'S Code (Optional) 14. RELATIONSHIP TO VETERAN Apt./Unit Number State/Province 12. CLAIMANT'S TELEPHONE EMAIL ADDRESS NUMBER (Include SECTION III: ORGANIZATION OF SERVICE 15. NAME organization) RECOGNIZED BY THE DEPARTMENT 3 before selecting INFORMATION list on Page AFFAIRS (See SERVICE ORGANIZATION OF VETERANS THE BEHALF OF organization ACTING ON of the entire the REPRESENTATIVE is an appointment on behalf of OF OFFICIAL ITEM 15 (This specific individual to act 16A. NAME NAMED IN only this ORGANIZATION the designation of indicate and does not organization) NAMED IN ITEM 15 16B. JOB TITLE OF PERSON NAMED IN ITEM 16A VA Form 21-22 must be fi lled out by a veteran to receive assistance from a VA-certifi ed service rep. If a claims rep is not asking you to fi ll out this form, move on. VFW’s National Veterans Service Director Ryan Gallucci said with Fiscal Year 21-22 well under way, VFW is calling this the Year of the Represented Veteran, given the importance of this form. 18. DATE OF OF THE ORGANIZATION THIS APPOINTMENT (MM/DD/YYYY) Page 1 21-22, AUG 2015. 17. EMAIL ADDRESS SUPERSEDES VA FORM FEB 2019 VA FORM 21-22 44 • VFW • FEBRUARY 2022