Manage Your Representative for VA Claims

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Let's Pre-Fill Your Form

To conveniently pre-fill a downloadable form with this representative's information and more, please answer the following questions.

If you don't want to do that, another option is to download a blank form and fill it out manually. Blank forms are available at the bottom of this page after closing this popup window.

Are you separated from the military?

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Your Current Mailing Address


Is this your current mailing address?

Don't worry, you don't have to correct your address to continue. To update your address at a later time, go to the eBenefits dashboard and use the Update Personal Contact Information for DEERS and VA Outreach feature.

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Are you also the Claimant?

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Download Your Form

The following form may contain Personally Identifiable Information (PII):



Print and complete one (1) copy of the VA Form 21-22a. Mail or hand-deliver it to either your servicing VA regional office or your agent, attorney, or non-licensed individual representative to submit on your behalf. Find the address of your local VA regional office.

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