Form 21-10210, the Lay/Witness Statement, is the Department of Veterans Affairs (VA) form for submitting a statement in support of a claim, often called a "buddy statement." A veteran or claimant, or someone writing on their behalf, uses it to describe what they know or have observed about the facts of the claim. On FillingPDF you can fill out the form online and download or print the completed PDF; VA publishes the original, and the statement reaches VA only through the channels described below.
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What is 21-10210?
VA Form 21-10210, Lay/Witness Statement, is the Department of Veterans Affairs form on which a veteran, a claimant or someone writing on their behalf gives a signed statement supporting a claim before VA.
The Veterans Benefits Administration (VBA) publishes the form. VA's forms page says it is used to submit a formal statement to support your own VA claim, or the claim of another veteran or an eligible family member, and notes that people also call it a "buddy statement."
The form has five sections:
- Section I: the veteran's identification information (items 1 to 8).
- Section II: the claimant's identification information, completed only if the claimant is not the veteran (items 9 to 16).
- Section III: the statement itself (item 17), where you describe what you yourself know or have observed about the facts or circumstances relevant to the claim.
- Section IV: the witness's contact information (items 18 to 21), completed when the statement comes from someone else.
- Section V: the certification and signature (items 22A and 22B).
The printed edition is dated JUL 2024 and supersedes the JUN 2021 edition. It carries OMB No. 2900-0881. The form warns that the law provides severe penalties, including fine or imprisonment, for willfully submitting a false statement of a material fact.
Who needs to file 21-10210?
The form is for anyone who wants to put a statement in support of a VA claim on the record. The instructions name two kinds of authors: the veteran or claimant, and someone writing on the veteran's or claimant's behalf. VA's forms page adds that the claim may be your own or that of another veteran or an eligible family member.
- Veteran: completes Section I. If the veteran is also the claimant, Section II stays blank.
- Claimant who is not the veteran: completes Section II as well as Section I, which holds the veteran's information.
- Witness or other person writing on the claimant's behalf: completes Sections IV and V along with the statement in Section III. The relationship boxes include served with the veteran/claimant, family/friend, coworker/supervisor, and other (specify); check all that apply.
Each statement needs its own form. If you want to add a statement of your own, or you have more than one witness, use a separate VA Form 21-10210 for each one. The statement should cover only what the writer personally knows or has observed.
When to file 21-10210
Submit Form 21-10210 whenever you or someone writing on your behalf is providing a statement to support a claim. The instructions say that if you are providing additional statements to support your claims, you should submit this form with your application. The form prints no separate due date. The deadline that matters is the one that applies to the claim the statement supports. VA estimates an average of 10 minutes per respondent to complete the form, including time to review the instructions and gather the information. Prepare one form per statement, so that each witness's statement can be signed and dated separately.
How to fill out 21-10210
Read the instructions and notices
Before you start, read the Privacy Act Notice and Respondent Burden on page 3. The form says that if you complete it by hand, you should print in ink, one letter per box, and fill in each applicable circle completely.
Enter the veteran's identification
In Section I, enter the veteran's name (item 1), Social Security number (item 2), VA file number if applicable (item 3), date of birth as MM/DD/YYYY (item 4) and VA insurance file number if applicable (item 5). The page headers on pages 2 and 3 also ask for the Social Security number.
Add the veteran's contact details
Item 6 is the current mailing address, if applicable, and item 7 is the telephone number with area code. Enter an e-mail address in item 8, and check the box there only if you agree to receive electronic correspondence from VA about the claim.
Complete Section II if needed
Fill in items 9 to 16 only if the claimant is not the veteran: name, Social Security number, VA file number, date of birth, VA insurance file number, mailing address, telephone and e-mail. If the claimant is the veteran, leave this section blank.
Indicate the claimed issue
At the top of Section III, note the claimed issue the statement addresses. Use a separate form for each additional statement or witness.
Write the statement
In item 17, describe what you yourself know or have observed about the facts or circumstances relevant to the claim before VA. If you need more room, continue in the continuation box in Section III.
Enter the witness's contact information
If the statement is from someone else writing on the claimant's behalf, complete Section IV: the witness's name (item 18), telephone number (item 20) and e-mail address (item 21).
Mark the relationship to the veteran
In item 19, check all that apply: served with veteran/claimant, family/friend, coworker/supervisor, or other, and specify the relationship if you choose other.
Sign and date the certification
In Section V, the veteran, claimant or witness signs in item 22A, which is required, and enters the date as MM/DD/YYYY in item 22B. The signature certifies that the information is true and correct to the best of the signer's knowledge and belief.
Review and download the completed PDF
Check that Section II is empty unless the claimant is not the veteran, and that Sections IV and V are complete for a witness statement. Download or print the completed PDF from FillingPDF, then send it through one of the channels under How to submit.
How to submit 21-10210
You can send Form 21-10210 to VA by mail, or submit the statement online instead of using the paper form.
- By mail: after completing the form, mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
- Online: VA's forms page says you can submit your statement online instead of sending the paper form, through the online tool at https://www.va.gov/supporting-forms-for-claims/lay-witness-statement-form-21-10210.
For questions, contact VA through Ask VA at https://ask.va.gov/ or call toll-free 1-800-827-1000 (TTY: 711). VA forms are available at www.va.gov/vaforms. Do not send the completed form to the VA Reports Clearance Officer email address printed in the burden notice, which is only for comments on the burden estimate. The form names no fee. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Filling in Section II when the claimant is the veteran; the form says to complete it only if the claimant is not the veteran.
- Putting statements from more than one witness, or an extra statement of your own, on a single form; the form calls for a separate VA Form 21-10210 for each statement.
- Leaving the signature in item 22A blank. It is marked REQUIRED, and the date goes in item 22B.
- Skipping Sections IV and V when the statement in Section III is from someone else writing on the claimant's behalf.
- Describing what others told you instead of what you yourself know or have observed, which is what item 17 asks for.
- Not indicating the claimed issue the statement addresses, which the note in Section III asks you to do.
- Writing in the VA DATE STAMP box, which is marked DO NOT WRITE IN THIS SPACE.
- Handwriting in pencil, putting more than one letter in a box or leaving applicable circles unfilled; the form asks for ink, one letter per box and completely filled circles.
- Emailing the completed form to the VA Reports Clearance Officer address, which the form says not to do.
Frequently asked questions
What is form 21-10210 used for?
Form 21-10210 is the VA Lay/Witness Statement. A veteran, a claimant or someone writing on their behalf uses it to give a signed statement of what they know or have observed about the facts of a claim before the Department of Veterans Affairs.
Is the Lay/Witness Statement the same as a buddy statement?
Yes. VA's forms page says people also call the statement submitted on VA Form 21-10210 a "buddy statement." It can support your own claim or the claim of another veteran or an eligible family member.
Can I submit a lay/witness statement online instead of mailing it?
Yes. VA's forms page says you can submit your statement online instead of sending the paper form, through the online tool on va.gov. If you prefer paper, mail the completed form to the Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Where do I mail VA Form 21-10210?
Mail it to Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. For questions, use Ask VA at https://ask.va.gov/ or call 1-800-827-1000 (TTY: 711).
Do I need a separate form for each witness?
Yes. If you want to submit an additional statement on your own behalf, or you have more than one witness writing on your behalf, the form says to use a separate VA Form 21-10210 for each statement.
Who signs the Lay/Witness Statement?
Item 22A, the veteran, claimant or witness signature, is marked REQUIRED, and item 22B is the date signed. When the statement is from someone else writing on the claimant's behalf, that person completes Sections IV and V.
When do I complete Section II of the form?
Only if the claimant is not the veteran. Section II (items 9 to 16) holds the claimant's information, while Section I always holds the veteran's. If the veteran is the claimant, leave Section II blank.
Can I fill out Form 21-10210 online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not submit the statement to VA; you send it through the mail or VA's online tool.
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