4138 21 4138x

User Manual: 4138

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OMB Approved No. 2900-0075
Respondent Burden: 15 minutes

STATEMENT IN SUPPORT OF CLAIM
PRIVACY ACT INFORMATION: The law authorizes us to request the information we are asking you to provide on this form (38 U.S.C. 501(a) and (b)). The
responses you submit are considered confidential (38 U.S.C. 5701). They may be disclosed outside the Department of Veterans Affairs (VA) only if the disclosure is
authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22, Compensation, Pension, Education and Rehabilitation
Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the law.
Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

SOCIAL SECURITY NO.

VA FILE NO.

C/CSS The following statement is made in connection with a claim for benefits in the case of the above-named veteran:

(CONTINUE ON REVERSE)

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
DATE SIGNED

SIGNATURE

ADDRESS
DAYTIME

TELEPHONE NUMBERS (Include Area Code)
EVENING

PENALITY: The law provides severe penalties which include fine or inprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false.
VA FORM
JUN 2000

21-4138

EXISTING STOCKS OF VA FORM 21-4138,
APR 1994, WILL BE USED
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