Form 20-10208 Document Evidence Submission

OMB Approved No. 2900-NEW
Respondent Burden: 5 Minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

DOCUMENT EVIDENCE SUBMISSION
INSTRUCTIONS: Read the Privacy Act and Respondent Burden on Page 2 before completing this form. This
form is used for the submission of additional documentation or evidence. For additional information you may
contact us through Ask VA at: 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. After completing the form, mail to: Department of Veterans Affairs,
Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

SECTION I: VETERAN/SERVICE MEMBER'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completing by hand, print neatly and legibly in ink, and completely fill in each applicable
check box to help expedite processing of the form.
1. VETERAN/SERVICE MEMBER'S NAME (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

4. DATE OF BIRTH (MM/DD/YYYY)

5. BDD CLAIMS ONLY: ANTICIPATED/FUTURE RELEASE FROM ACTIVE DUTY (RAD) DATE: (MM/DD/YYYY)

6. 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

City
Country

ZIP Code/Postal Code
8. E-MAIL ADDRESS

7. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION
(If other than veteran/service member)
9. CLAIMANT'S NAME (First, Middle Initial, Last)

10. SOCIAL SECURITY NUMBER

11. VA FILE NUMBER (If applicable)

12. DATE OF BIRTH (MM/DD/YYYY)

13. 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

City
Country

14. TELEPHONE NUMBER (Include Area Code)

ZIP Code/Postal Code
15. E-MAIL ADDRESS

Enter International Phone Number (If applicable)

VA FORM
XXX 20XX

20-10208

SUPERSEDES VA FORM 20-10208, AUG 2023.

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VETERAN/SERVICE MEMBER/CLAIMANT'S SOCIAL SECURITY NO.

SECTION III: DOCUMENT/EVIDENCE TYPE YOU ARE SUBMITTING
16. IS THIS FORM BEING SUBMITTED IN RESPONSE TO A REQUEST YOU RECEIVED FROM VA?
YES

NO

17. IDENTIFY THE DOCUMENT(S) OR EVIDENCE YOU ARE SUBMITTING

NOTE: You may select one or more type(s), depending on the type of documentation/evidence being provided with this form.
BIRTH CERTIFICATE

DEATH CERTIFICATE

DEPENDENCY INFORMATION

DIVORCE DECREE

FINANCIAL INFORMATION

MARRIAGE CERTIFICATE

MEDICAL TREATMENT RECORDS

COURT PAPERS/DOCUMENTS

MILITARY PERSONNEL RECORDS

SERVICE TREATMENT RECORDS

AUTHORIZED REPRESENTATIVE ONLY: Request to initiate electronic service treatment record (eSTR) transfer for a future BDD application
OTHER (Describe)

NOTE: If you need to submit a statement as a veteran/service member/claimant or someone writing on your behalf to support your claim, use VA Form
21-10210, Lay/Witness Statement. VA Forms are available at https://www.va.gov/vaforms/.
SECTION IV: CERTIFICATION AND SIGNATURE
I CERTIFY THAT I have filled this form out completely and that it is true and correct to the best of my knowledge and belief.
18A. VETERAN/SERVICE MEMBER/CLAIMANT'S SIGNATURE (REQUIRED)

18B. DATE SIGNED (MM/DD/YYYY)

SECTION V: AUTHORIZED REPRESENTATIVE'S SIGNATURE
(Valid only if the veteran/service member/claimant did not sign Item 18A and has an authorized representative)
I CERTIFY THAT the veteran/service member/claimant has authorized me as the undersigned representative and certifies that the information contained in
this document is true and complete to the best of the veteran/service member/claimant's knowledge.

NOTE: A signature in this section 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.

19A. AUTHORIZED REPRESENTATIVE'S SIGNATURE

19B. POA CODE

19D. ACCREDITATION NUMBER

19E. DATE (MM/DD/YYYY) LAST VA FORM 21-22 OR 21-22A WAS SUBMITTED (If known)

19C. DATE SIGNED (MM/DD/YYYY)

PENALTY: 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.
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, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your
obligation to respond is voluntary.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-NEW, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average5 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer
at vapra@va.gov. Please refer to OMB Control No. 2900-NEW in any correspondence. Do not send your completed VA Form 20-10208 to this email address.
VA FORM 20-10208, XXX 20XX

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