SECTION I: VETERAN'S IDENTIFICATION INFORMATION
SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION
(Complete this section ONLY IF the claimant is NOT the veteran)
Page 1
LAY/WITNESS STATEMENT
VA FORM
JUN 2021
21-10210
Before completing this form, read the Privacy Act and Respondent Burden on page 3. Use this form to
submit a statement as a veteran/claimant or someone writing on your behalf to support a claim. If you or someone else
writing on your behalf are providing additional statement(s) to support your claim(s) please submit this form with your
application. For more information, contact us at https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use
a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711. VA forms are available at
www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs, Evidence Intake Center, P.
O. Box 4444, Janesville, WI 53547-4444.
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
OMB Approved No. 2900-0881
Respondent Burden: 10 Minutes
Expiration Date: 06/30/2024
You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box,
and completely fill in each applicable circle to help expedite processing of the form.
8. E-MAIL ADDRESS
4. DATE OF BIRTH
(MM/DD/YYYY)
3. VA FILE NUMBER (If applicable)
2. SOCIAL SECURITY NUMBER
1. VETERAN'S NAME
(First, Middle Initial, Last)
5. VA INSURANCE FILE NUMBER (If applicable)
6. CURRENT MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
7. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number
(If applicable)
I agree to receive electronic correspondence from VA in regards to my claim.
9. CLAIMANT'S NAME (First, Middle Initial, Last)
SUPERSEDES VA FORM 21-10210, AUG 2020.
INSTRUCTIONS:
NOTE:
YearDayMonth
No. &
Street
Apt./Unit Number
State/Province Country ZIP Code/Postal Code
City
16. E-MAIL ADDRESS
12. DATE OF BIRTH
(MM/DD/YYYY)
11. VA FILE NUMBER (If applicable)
10. SOCIAL SECURITY NUMBER
13. VA INSURANCE FILE NUMBER
(If applicable)
14. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
15. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number
(If applicable)
I agree to receive electronic correspondence from VA in regards to my claim.
YearDayMonth
No. &
Street
Apt./Unit Number
State/Province Country ZIP Code/Postal Code
City