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APPOINTMENT OF VETERANS SERVICE ORGANIZATION

AS CLAIMANT'S REPRESENTATIVE

OMB Control No. 2900-0321

Respondent Burden: 5 minutes

1. LAST-FIRST-MIDDLE NAME OF VETERAN

2. VA FILE NUMBER (Include prefix)

3A. NAME OF SERVICE ORGANIZATION RECOGNIZED BY THE DEPARTMENT OF VETERANS AFFAIRS (See list on reverse side before selecting organization)

INSTRUCTIONS - TYPE OR PRINT ALL ENTRIES

USE

ONLY

5. INSURANCE NUMBER(S) (Include letter prefix)

6B. BRANCH OF SERVICE

8. RELATIONSHIP (If other than veteran)

Note - If you would prefer to have an individual assist you with your claim, you may use VA Form 21-22a, " Appointment of

Individual As Claimant's Representative."

VA FORM

NOV 2005

21-22

SUPERSEDES VA FORM 21-22, JUN 2003,

WHICH WILL NOT BE USED.

9. ADDRESS OF CLAIMANT (No. and street or rural route, city or P.O., State and ZIP Code)

10. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)

I, the claimant named in Items 1 or 7, hereby appoint the service organization named in Item 3A as my representative to prepare,

present and prosecute my claim for any and all benefits from the Department of Veterans Affairs based on the service of the veteran

named in Item 1. I authorize the Department of Veterans Affairs to release any and all of my records, to include disclosure of my

Federal tax information (other than as provided in Items 12 and 13), to that service organization appointed as my representative. It is

understood that no fee or compensation of whatsoever nature will be charged me for service rendered pursuant to this power of

attorney. I understand that the service organization I have appointed as my representative may revoke this power of attorney at any

time, subject to 38 CFR 20.608. Additionally, in those cases where a veteran's income is being developed because of an income

verification necessitated by an Internal Revenue Service verification match, the assignment of the service organization as the veteran's

representative is only valid for five years from the date this form is signed for purposes restricted to the verification match. Signed and

accepted subject to the foregoing conditions.

12. AUTHORIZATION FOR REPRESENTATIVE'S ACCESS TO RECORDS PROTECTED BY SECTION 7332, TITLE 38, U.S.C.

Unless I check the box below, I do not authorize VA to disclose to the service organization named on this appointment form

any records that may be in my file relating to treatment for drug abuse, alcoholism or alcohol abuse, infection with the human

immunodeficiency virus (HIV), or sickle cell anemia.

I authorize the VA facility having custody of my VA claimant records to disclose to the service organization named in Item 3A all treatment

records relating to drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia.

Redisclosure of these records by my service organization representative, other than to VA or the Court of Appeals for Veterans Claims, is not

authorized without my further written consent. This authorization will remain in effect until the earlier of the following events: (1) I revoke

this authorization by filing a written revocation with VA; or (2) I revoke the appointment of the service organization named above, either by

explicit revocation or the appointment of another representative.

THIS POWER OF ATTORNEY DOES NOT REQUIRE EXECUTION BEFORE A NOTARY PUBLIC

14. SIGNATURE OF CLAIMANT (Do Not Print)

15. DATE SIGNED

VA FORM 21-22-1 SENT TO:

REVOKED (Reason and date)

CH. 30

DEA FILE

INSURANCE

FILE

CER FILE

LG FILE

EDU FILE

ACKNOWLEDGED

(Date)

DATE SENT

NOTE: As long as this appointment is in effect the organization named herein will be recognized as the sole agent for presentation of

your claim before the Department of Veterans Affairs in connection with your claim or any portion thereof.

11. DATE OF THIS APPOINTMENT

A. DAYTIME

B. EVENING

13. LIMITATION OF CONSENT - My consent in Item 12 for the disclosure of records relating to treatment for drug abuse, alcoholism or alcohol

abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia is limited as follows:

IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN ON REVERSE BEFORE COMPLETING THE FORM

3B. JOB TITLE OF OFFICIAL REPRESENTATIVE AUTHORIZED TO ACT ON VETERAN'S BEHALF

4. SOCIAL SECURITY NUMBER

6A. SERVICE NUMBER(S)

7. NAME OF CLAIMANT (If other than veteran)

RECOGNIZED SERVICE ORGANIZATIONS

African American PTSD Association

American Legion

American Red Cross

AMVETS

American Ex-Prisoners of War, Inc.

American Defenders of Bataan and Corregidor, Inc.

American GI Forum, National Veterans Outreach Program

Armed Forces Services Corporation

Army and Navy Union, USA

Blinded Veterans Association

Catholic War Veterans of the U.S.A.

Disabled American Veterans

Eastern Paralyzed Veterans Association

Fleet Reserve Association

Gold Star Wives of America, Inc.

Italian American War Veterans of the United States, Inc.

Jewish War Veterans of the United States

Legion of Valor of the United States of America, Inc.

Marine Corps League

Military Order of the Purple Heart

National Amputation Foundation, Inc.

National Association of County Veterans Service Officers, Inc.

National Association for Black Veterans, Inc.

National Veterans Legal Services Program

National Veterans Organization of America

Non Commissioned Officers Association of the USA

Navy Mutual Aid Association

Paralyzed Veterans of America, Inc.

Polish Legion of American Veterans, U.S.A.

Swords to Plowshares, Veterans Rights Organization, Inc.

The Retired Enlisted Association

The Veterans Assistance Foundation, Inc.

The Veterans of the Vietnam War, Inc. & The Veterans

Coalition

United Spanish War Veterans of the United States

Veterans of Foreign Wars of the United States

Veterans of World War I of the U.S.A., Inc.

Vietnam Era Veterans Association

Vietnam Veterans of America

Although agency titles vary, the following States and possessions maintain veterans service agencies which are recognized to present

claims.

Guam

Hawaii

Idaho

Illinois

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

North Carolina

North Dakota

Northern Mariana Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Virgin Islands

Washington

West Virginia

Wisconsin

PRIVACY ACT NOTICE: 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,

Compensation, Pension, Education, and Rehabilitation Records-VA, published in the Federal Register. Your obligation to respond is

voluntary. However, the requested information is considered relevant and necessary to recognize a service organization as your

representative and/or identify disclosable records. 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. 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.

The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through

computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to recognize the service organization you name to act on your behalf in the

preparation, presentation, and prosecution of claims for VA benefits (38 U.S.C. 5902). We will also use the information to identify any

VA records that we may disclose to the service organization (38 U.S.C. 5701(b)). 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get

information on where to send comments or suggestions about this form.

Alabama

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Membership in an organization is not a prerequisite to appointment of the organization as claimant's representative.

The following is a listing of National Organizations recognized by the Secretary in the preparation and prosecution of claims under

laws administered by the Department of Veterans Affairs.

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

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