DEPARTMENT OF VETERANS AFFAIRS
In Reply Refer To:
We wish to act promptly on your recent correspondence, but because of insufficient or inaccurate information we cannot identify the proper record. We will be glad to make a further search if you can supply additional identifying data. The information requested below will help us. Please complete as many of the items as possible and RETURN THIS LETTER TO US WITH YOUR ORIGINAL CORRESPONDENCE (if enclosed). The information is solicited under authority of Title 38, United States Code. Disclosure is voluntary; however, if it is not furnished, we will be unable to take further action on your correspondence. Failure to furnish this information will have no other adverse effect. Sincerely yours,
Form Approved, OMB No. 2900-0028 Respondent Burden: 5 minutes
PRIVACY ACT STATEMENT: The information requested on this form is solicited under Title 38, United States Code, and will authorize release of the information you specify. The information may also be disclosed outside VA as permitted by law to include disclosures as stated in the Notices of Systems of VA Records published in the Federal Register in accordance with the Privacy Act of 1974. The information requested is necessary to ensure that the statutory requirements of the Privacy Act of 1974 and VA's confidentiality statue are met. 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. Responding to this collection of information is voluntary. However, if the information is not furnished, we may not be able to comply with your request. Public reporting burden for this collection of information is estimated to average 5 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to VA Clearance Officer (005E3), 810 Vermont Avenue, NW, Washington, DC 20420. SEND COMMENTS ONLY. PLEASE DO NOT SEND APPLICATIONS FOR BENEFITS TO THIS ADDRESS.
1. CLAIM FILE NO. (Include prefix) 2. INSURANCE FILE NO. OR OTHER INSURANCE NOS. (Include prefix)
3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN
4. SOCIAL SECURITY NO.
5. SERVICE NO.
6. DATE ENTERED SERVICE (Month, Day, Year)
7. DATE OF SEPARATION (Month, Day, Year)
8. DATE OF BIRTH (Month, Day, Year)
9. DATE OF DEATH, IF DECEASED (Month, Day, Year)
10. SIGNATURE OF REQUESTOR
11. TELEPHONE NO. (Include Area Code)
FL 70-2 JUL 2002 (RS)