Free VA Form VA21 - Application for Accreditation as Service Organization Representative - Federal

Form Approved: OMB No. 2900-0018 Respondent Burden: 15 minutes

APPLICATION FOR ACCREDITATION AS SERVICE ORGANIZATION REPRESENTATIVE
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE: The information requested on this form is solicited under 38 U.S.C., Section 5902, which authorizes VA to recognize representatives of approved organizations for the preparation, presentation, and prosecution of claims under laws administered by VA. The requested information will enable VA to determine your eligibility for accreditation as a representative of a recognized service organization. Your disclosure of this information to us is voluntary, but your failure to provide full information could delay or preclude your accreditation. The Privacy Act authorizes VA to disclose the information outside VA for certain routine uses, which have been published in the Federal Register with reference to a VA system of records entitled, "Current and Former Accredited Representative, Claims Agent, and Representative and Claims Agent Applicant and Rejected Applicant Records-VA" (01VA022). Such routine uses include verification of the identity, status, and service organization affiliation of representatives, civil or criminal law enforcement, communnications with members of Congress of their representatives, Government litigation, and notification to service organizations of information relevant to a refusal to grant or a suspension or termination of accreditation. RESPONDENT BURDEN: VA may not conduct or sponsor, and you are not required to respond to, this collection of information unless it displays a valid OMB Control Number. The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching 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 (005G2), 810 Vermont Avenue, NW, Washington, DC 20420. Send comments only. Do not send this form or requests for benefits to this address. SECTION I - TO BE EXECUTED BY DESIGNEE (Type or print)
1. LAST NAME - FIRST NAME - MIDDLE NAME 2. BUSINESS ADDRESS

3. BRANCH OF SERVICE (Check applicable boxes) ARMY NAVY AIR FORCE MARINE CORPS COAST GUARD NON-VETERAN OTHER (Specify) 4. LIST OF DATES OF ALL ACTIVE SERVICE 5. CHARACTER OF DISCHARGE(S) 6. METHOD OF QUALIFICATION COMPLETED VA APPROVED COURSE PASSED VA APPROVED EXAMINATION EXPERIENCE 7A. NAME OF ORGANIZATION WHICH YOU WILL REPRESENT

7B. RELATIONSHIP TO ORGANIZATION
ARE YOU A MEMBER IN GOOD STANDING OF THE ORGANIZATION SHOWN IN ITEM 7A? ARE YOU A PAID EMPLOYEE OF THE ORGANIZATION SHOWN IN ITEM 7A, WORKING FOR THE ORGANIZATION FOR NOT LESS THAN 1000 HOURS ANNUALLY?

7C. COUNTY VETERANS SERVICE OFFICERS
ARE YOU A PAID COUNTY EMPLOYEE: A) WHO WORKS FOR THE COUNTY NOT LESS THAN 1000 HOURS ANNUALLY; B) WHO HAS SUCCESSFULLY COMPLETED VA-APPROVED STATE TRAINING AND EXAMINATION; AND C) WHO WILL RECEIVE REGULAR STATE SUPERVISION AND MONITORING OR ANNUAL TRAINING? YES NO

YES

NO

YES

NO

8. ARE YOU ACCREDITED TO ANY OTHER ORGANIZATION(S)? YES NO (If "YES," give name of organization(s)) 9B. HAVE YOU EVER HELD A FEDERAL GOVERNMENT POSITION WHICH INVOLVED ANY ACTION RESPECTING CLAIMS IN THE DEPARTMENT OF VETERANS AFFAIRS OR THE VETERANS ADMINISTRATION? YES NO

9A. ARE YOU EMPLOYED IN ANY CIVIL OR MILITARY DEPARTMENT OR AGENCY OF THE UNITED STATES GOVERNMENT? YES NO (If "YES," give name of agency or department)

It is understood and agreed that neither the designee nor the organization will charge or accept any fee or other gratuity for services rendered a claimant; that neither will publish or divulge any confidential information except as provided by law or regulation; and that any breach of these conditions will be sufficient basis for revocation of accreditation.
10. SIGNATURE OF DESIGNEE 11. DATE OF SIGNATURE

CERTIFICATION: Subject to the foregoing agreement, the undersigned hereby certifies that the designee is of good character and reputation, is qualified by ability and experience to present claims, and that the foregoing statements are believed to be correct. We therefore recommend accreditation.
12. SIGNATURE AND TITLE OF CERTIFYING OFFICER 13. NAME OF ORGANIZATION

SECTION II - TO BE EXECUTED BY PROPER CERTIFYING OFFICER OF RECOGNIZED ORGANIZATION

14. ADDRESS OF CERTIFYING OFFICER

15. DATE OF SIGNATURE

PENALTY: The law provides that whoever makes any statement of a material fact, knowing it to be false, shall be punished by a fine or imprisonment or both (18 U.S.C. 1001).
VA FORM JUL 2007

21

Supersedes VA Form 21, JUN 1992, Which Will Not Be Used.

Adobe LiveCycle Designer 7.1