20-10206 INFORMATION AND INSTRUCTIONS ON HOW TO

RECORDS CUSTODIAN

MAIL or FAX TO

Centralized Support Division

Claim Files, Service Treatment Records/

Military Treatment Records,

DD Form 214, C&P Exams etc.

To help us locate requested records, please include your Social Security number (SSN) or Alien Registration number (A-

number).

Department of Veterans Affairs

Evidence Intake Center

PO Box 4444

Janesville, WI 53547-4444

Toll-free Phone: 1-800-827-1000

Toll-free Fax: (844) 531-7818

VA FORM

AUG 2023

20-10206

INFORMATION AND INSTRUCTIONS ON HOW TO SUBMIT

A FREEDOM OF INFORMATION ACT (FOIA) OR PRIVACY ACT REQUEST (PA)

Page 1

WHERE TO SEND YOUR REQUEST:

All Privacy Act requests must be sent to the Centralized Support Division address listed below.

IMPORTANT: This form is ONLY used to request military records or a veteran's benefit records.

Please complete the attached form to submit a Freedom of Information Act (FOIA) or Privacy Act (PA) request. It must be signed by the

requester, veteran or third-party authorized to act on behalf of the requester.

WHAT IS A FOIA REQUEST?

A FOIA request provides the public the right to request access to records from Federal agencies, except those protected by the nine FOIA

exemptions. For additional information please visit https://www.va.gov/FOIA/index.asp.

WHAT IS A PA REQUEST?

A citizen of the United States or an alien lawfully admitted for permanent residence may request access to or amendment of records on

herself/himself from a System of Records (SORs). Examples of PA records are personal Claims Files (C-File), educational loan, and

beneficiary records. For additional information please visit https://www.oprm.va.gov/privacy/.

VERIFICATION OF IDENTITY AND CONSENT FOR PA REQUESTS ONLY

A request must include the following information:

•

Your full name;

•

Your date of birth;

•

Your place of birth;

•

Your current mailing address; and

•

Handwritten signature is required.

NOTE:

SECTION I: REQUEST FOR INFORMATION ON YOURSELF

(If you are seeking information on yourself, complete Sections I, III or IV, VI, VII and VIII. Complete Section VI, if applicable)

SECTION II: REQUEST FOR INFORMATION ON A PERSON OTHER THAN YOURSELF

(If you are seeking information on an individual other than yourself, complete

Sections II, III or IV, V, VII and IX or X. Complete Section VI, if applicable)

FREEDOM OF INFORMATION ACT (FOIA) OR PRIVACY ACT (PA) REQUEST

Read the Privacy Act and Respondent Burden information on Page 4 before completing the form. This

form must be signed by the requester, authorized organization, or third party who has been authorized by the requester. For

additional information on VA FOIA and PA requests visit our website at https://www.va.gov/FOIA/Requests.asp. You may

also contact us online through Ask VA: https://ask.va.gov/ or call us toll-free at 1-800-698-2411 (TTY: 711). VA forms are

available at www.va.gov/vaforms.

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

OMB Approved No. 2900-0877

Respondent Burden: 5 Minutes

Expiration Date: 08/31/2026

You may complete the form on-line or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and completely fill in each

applicable check box to help expedite processing of the form.

9. E-MAIL ADDRESS

5. DATE OF BIRTH

(MM/DD/YYYY)

4. VA FILE NUMBER (If applicable)

2. SOCIAL SECURITY NUMBER

1. NAME

(First, Middle Initial, Last)

6. PLACE OF BIRTH (Provide City and State, County and State or City and Country)

3. ALIEN REGISTRATION NUMBER (A-number)

(If applicable)

8A. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number

(If applicable)

8B. FAX NUMBER (If applicable)

Enter International FAX Number

(If applicable)

I agree to receive electronic correspondence from VA.

10. NAME

(First, Middle Initial, Last) OR YOUR ORGANIZATION'S NAME

11. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

12A. TELEPHONE NUMBER (Include Area Code) 12B. FAX NUMBER (If applicable)

INSTRUCTIONS:

YearDayMonth

7. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province Country ZIP Code/Postal Code

City

Enter International Phone Number

(If applicable)

Enter International FAX Number

(If applicable)

No. &

Street

Apt./Unit Number

State/Province Country ZIP Code/Postal Code

City

VA FORM

AUG 2023

20-10206

Page 2

NOTE:

SECTION III: COMPENSATION AND PENSION RECORDS REQUEST

(This information is required in order to complete the request)

SECTION IV: ALL OTHER BENEFIT RECORDS REQUEST

(This information is required in order to complete the request)

SECTION II: REQUEST FOR INFORMATION ON A PERSON OTHER THAN YOURSELF (Continued)

(If you are seeking information on an individual other than yourself, complete Sections II, III or IV, V, VII and IX or X.

Complete Section VI, if applicable)

SECTION VII: WILLINGNESS TO PAY FEES

SECTION V: VA REGIONAL OFFICE INFORMATION (If known)

SECTION VI: REMARKS

20. REMARKS (If any)

Items 13 through 16 must be completed to inform VA on whom the person is you are requesting the information about.

13. NAME OF THE PERSON YOU ARE REQUESTING INFORMATION ON (First, Middle Initial, Last)

SOCIAL SECURITY NUMBER

17. SELECT THE TYPE(S) OF RECORDS YOU ARE REQUESTING, BELOW:

CLAIMS FILE (C-FILE) SERVICE TREATMENT RECORDS / MILITARY TREATMENT RECORDS

VETERAN READINESS AND EMPLOYMENT RECORDS

PENSION BENEFIT DOCUMENTS

DD FORM 214

FIDUCIARY SERVICES RECORDS

EDUCATION BENEFIT RECORDS

DISABILITY EXAMINATIONS (C & P EXAMS) (If applicable enter date of exam in Section VI, Item 20, Remarks)

HOME LOAN BENEFIT RECORDS

FINANCIAL RECORDS (If applicable, specify which records are being requested in Section VI, Item 20, Remarks)

OFFICIAL MILITARY PERSONNEL FILE (OMPF)

LIFE INSURANCE BENEFIT RECORDS (If applicable, enter policy number in Section VI, Item 20, Remarks)

OTHER (Specify):

An agency may grant fee waivers if the requester successfully demonstrates that disclosure of information is in the publics interest because it is likely to contribute

significantly to the public understanding of the operations or activities of the government and is not primarily in the commercial interest of the requester.

I AM WILLING TO PAY THE APPLICABLE FEES UP TO THE AMOUNT OF

IF YOU BELIEVE YOU ARE ENTITLED TO A FEE WAIVER OR EXPEDITED PROCESSING, PLEASE INDICATE:

.00

18. SELECT THE TYPE(S) OF RECORDS YOU ARE REQUESTING, BELOW:

OTHER (Specify):

19. PROVIDE NAME OF VA REGIONAL OFFICE YOU ARE ASSOCIATED WITH

16. VA FILE NUMBER (If applicable)

14. SOCIAL SECURITY NUMBER

15. ALIEN REGISTRATION NUMBER

(A-number)

(If applicable)

21.

IMPORTANT:

For the purpose of fees only, FOIA divides requesters into three categories: (1) commercial requesters may be charged fees for searching for

records, reviewing the records, and photocopying them; (2) educational, non-commercial scientific institutions, and representatives of the news media are charged

for photocopying after the first 100 pages; (3) all other requesters (requesters who do not fall into any of the other two categories) are charged for photocopying

after the first 100 pages and for time spent searching for records in excess of two hours. VA charges $0.15 per single-sided page for photocopying. Actual costs

are charged for a format other than paper copies.

Page 3

VA FORM 20-10206, AUG 2023

NOTE:

SECTION VIII: REQUESTER CERTIFICATION AND SIGNATURE

SECTION IX: THIRD-PARTY CERTIFICATION AND SIGNATURE

(Valid only if Section II has been completed and requester has an authorized third party)

SECTION X: POWER OF ATTORNEY (POA) CERTIFICATION AND SIGNATURE

(Valid only if Section II has been completed and requester has authorized POA representation)

SOCIAL SECURITY NUMBER

Page 4

VA FORM 20-10206, AUG 2023

22A. REQUESTER'S SIGNATURE (REQUIRED) (SIGN IN INK) 22B. DATE SIGNED (MM/DD/YYYY)

A third-party signature will not be accepted unless a valid VA Form 21-0845, Authorization to Disclose Personal Information to a Third Party is of record or

completed and attached to this request. A third-party may be a family member or other designated person who is not a Power of Attorney, agent, or fiduciary.

I CERTIFY THAT I have completed this FOIA/PA request and declare it is true and correct to the best of my knowledge and belief.

I CERTIFY THAT the requester has authorized me as the undersigned representative and certifies that the truth and completion of the information contained in this

document is to the best of the requesters knowledge and belief.

23A. THIRD-PARTY SIGNATURE (Sign in ink) 23B. DATE SIGNED (MM/DD/YYYY)

The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact

knowing it to be false, or for fraudulent receipt of any document to which you are not entitled.

I CERTIFY THAT the requester has authorized me as the undersigned representative and certifies the truth and completion of the information contained in this

document to the best of the requesters knowledge and belief.

24A. POA/AUTHORIZED REPRESENTATIVE SIGNATURE (Sign in ink) 24B. DATE SIGNED (MM/DD/YYYY)

A POA's signature will not be accepted unless a valid VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative or VA

Form 21-22a, Appointment of Individual as Claimant's Representative is of record or attached to this request.

YearDayMonth

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, 58VA21/22/28, Compensation, Pension, Education, Veteran Readiness and Employment Records - VA, published in the

Federal Register. Your obligation to respond is voluntary.

PRIVACY ACT INFORMATION:

RESPONDENT BURDEN: We need this information to identify and obtain the information you are requesting. 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

PENALTY:

NOTE: