This form contains 161 fields organized into 47 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
20A: Currently Homeless (Yes/No)
20A - YES	Radiobutton	Check this box if you are currently homeless or at risk of becoming homeless (if checked, complete Items 20B through 20D about your living situation).
20A - NO	Radiobutton	Check this box if you are not currently homeless and not at risk of becoming homeless (if checked, skip to Item 21).
20B: Living Situation (Select all that apply, including Other)
20B - I live or sleep in a place that is not meant for regular sleeping	Checkbox	Check this box if you currently sleep or live in a place not meant for regular sleeping (for example, a car, park, abandoned building, bus or train station, airport, or campground). Fill only if '20A - YES' is 'Yes'.
20B - I live in a shelter	Checkbox	Check this box if you currently stay in a shelter or in a hotel/motel that is being used for temporary shelter. Fill only if '20A - YES' is 'Yes'.
20B - I am staying with a friend or family member because I am unable to own a home right now	Checkbox	Check this box if you are temporarily staying with friends or family because you cannot secure or afford your own housing. Fill only if '20A - YES' is 'Yes'.
20B - In the next 30 days, I will have to leave a facility, like a homeless shelter	Checkbox	Check this box if you expect to be required to leave a facility (for example, a homeless shelter) within the next 30 days. Fill only if '20A - YES' is 'Yes'.
20B - In the next 30 days, I will lose my home	Checkbox	Check this box if you expect to lose your current housing (house, apartment, trailer, or other living space) within the next 30 days. Fill only if '20A - YES' is 'Yes'.
20B - Other (Specify)	Checkbox	Check this box if your living situation is not listed above and you want to specify additional details in the space provided. Fill only if '20A - YES' is 'Yes'.
20B. Other living situation (specify)	Text	If none of the listed options describe your living situation, briefly describe the other situation here so the VA can understand your current housing risk. Fill only if '20B - Other (Specify)', '20A - YES' is 'Yes' for all fields.
20B - None of these situations apply to me	Checkbox	Check this box if none of the listed living situations describe your current circumstances. Fill only if '20A - YES' is 'Yes'.
20C: Point of Contact (Name)
20C: Point of Contact (Name)	Text	Enter the full name of the person the VA can contact to reach you (a friend, family member, or other designated contact). Fill only if '20A - YES' is 'Yes'.
20D: Point of Contact Telephone Number
20D: Area Code	Text	Enter the 3-digit area code for the point of contact's telephone number (do not include parentheses). Fill only if '20A - YES' is 'Yes'. Max length: 3 characters
20D: Prefix	Text	Enter the next three digits (central office/exchange) of the point of contact's telephone number. Fill only if '20A - YES' is 'Yes'. Max length: 3 characters
20D: Line Number	Text	Enter the final four digits of the point of contact's local telephone number. Fill only if '20A - YES' is 'Yes'. Max length: 4 characters
20D: International Phone Number	Text	If applicable, enter the full international phone number including country code and any necessary prefixes; leave blank if not applicable. Fill only if '20A - YES' is 'Yes'.
22A Other Treatment Location - Specify
22A Other Treatment Location (Specify)	Text	Enter the name and location details of the other treatment provider or facility not listed above (e.g., clinic or provider name, city/state) so VA can identify where you received treatment. Fill only if '22A - Other (Specify)' is 'Yes'. Depends on: 22A - Other (Specify)
22A Treatment Received - Locations (Check all that apply)
22A - Private Health Care Provider (including non-Federal records)	Checkbox	Check this box if you have received treatment from a private health care provider (including non‑Federal records).
22A - VA Vet Center	Checkbox	Check this box if you have received treatment at a VA Vet Center.
22A - Community Care (Paid for by VA)	Checkbox	Check this box if you have received community care that was paid for by the VA.
22A - VA Medical Center(s) (VAMC) and Community‑Based Outpatient Clinics (CBOC)	Checkbox	Check this box if you have received treatment at a VA Medical Center (VAMC) or a Community‑Based Outpatient Clinic (CBOC).
22A - Department of Defense (DOD) Military Treatment Facility(ies) (MTF)	Checkbox	Check this box if you have received treatment at a Department of Defense (DoD) military treatment facility (MTF).
22A - Other (Specify)	Checkbox	Check this box if you received treatment at a location not listed above and specify the location on the provided line.
22B-22D Treatment Facility Row 1
22D (Row 1) Don't have date	Checkbox	Check this box if you do not have the date(s) of treatment for the facility entered in Row 1.
Row 1 - Treatment year (22C)	Number	Enter the year when the treatment occurred. Fill only if '22D (Row 1) Don't have date' is 'No'. Max length: 4 characters Depends on: 22D (Row 1) Don't have date
Row 1 - Treatment month (22C)	Text	Enter the month when the treatment occurred as a one- or two-digit number (MM). Fill only if '22D (Row 1) Don't have date' is 'No'. Max length: 2 characters Depends on: 22D (Row 1) Don't have date
Row 1 - Treatment facility name and location (22B)	Text	Enter the full name and location of the treatment facility where you received care (for example, facility name and city/state or address).
22B-22D Treatment Facility Row 2
Row 2 Treatment Facility Name and Location	Text	Enter the name and location of the treatment facility where you received care (for example, facility name, city, and state).
22D (Row 2) - Don't have date	Checkbox	Check this box if you do not have the date(s) of treatment for the facility entered on row 2.
Row 2 Treatment End Date	Date	Enter the approximate date when treatment at this facility ended, or leave blank if treatment is ongoing or unknown. Fill only if '22D (Row 2) - Don't have date' is 'No'. Max length: 4 characters Depends on: 22D (Row 2) - Don't have date
Row 2 Treatment Start Date	Date	Enter the approximate date when treatment at this facility began. Fill only if '22D (Row 2) - Don't have date' is 'No'. Max length: 2 characters Depends on: 22D (Row 2) - Don't have date
22B-22D Treatment Facility Row 3
22B Treatment facility name and location (Row 3)	Text	Enter the full name and city/state (or other location) of the treatment facility where the care was received for this row.
Row 3 - Don't have date	Checkbox	Check this box if you do not have the date(s) of treatment for the treatment facility listed in row 3.
22C Date of treatment - Year (Row 3)	Text	Enter the year (YYYY) when the treatment began or took place for this facility row; you may provide an approximate year if exact is unknown. Fill only if 'Row 3 - Don't have date' is 'No'. Max length: 4 characters Depends on: Row 3 - Don't have date
22C Date of treatment - Month (Row 3)	Text	Enter the month (MM) when the treatment began or took place for this facility row; you may provide an approximate month if exact is unknown. Fill only if 'Row 3 - Don't have date' is 'No'. Max length: 2 characters Depends on: Row 3 - Don't have date
Alternate Signer Date Signed (28B)
28B - Month (MM)	Text	Enter the month portion of the alternate signer date in two digits (MM), e.g., 01 for January. Max length: 2 characters
28B - Day (DD)	Text	Enter the day portion of the alternate signer date in two digits (DD), e.g., 05 for the fifth day of the month. Max length: 2 characters
28B - Year (YYYY)	Text	Enter the year portion of the alternate signer date as four digits (YYYY), e.g., 2026. Max length: 4 characters
Benefit Type
Compensation	Radiobutton	Check this box if you are submitting a supplemental claim for VA compensation benefits (disability compensation).
Education	Radiobutton	Check this box if you are submitting a supplemental claim for VA education benefits.
Veteran Readiness and Employment	Radiobutton	Check this box if you are submitting a supplemental claim for Veteran Readiness and Employment services or benefits.
Pension/DIC/Survivors Benefits	Radiobutton	Check this box if you are submitting a supplemental claim for pension, Dependency and Indemnity Compensation (DIC), or other survivors benefits.
Loan Guaranty	Radiobutton	Check this box if you are submitting a supplemental claim related to VA loan guaranty benefits.
National Cemetery Administration	Radiobutton	Check this box if you are submitting a supplemental claim for benefits or services from the National Cemetery Administration.
Fiduciary	Radiobutton	Check this box if you are submitting a supplemental claim related to fiduciary benefits or a fiduciary decision.
Life Insurance	Radiobutton	Check this box if you are submitting a supplemental claim for VA life insurance benefits.
Veterans Health Administration	Radiobutton	Check this box if you are submitting a supplemental claim for a Veterans Health Administration (VHA) benefit and specify the particular VHA benefit (e.g., travel/mileage reimbursement, medical treatment reimbursement, health care eligibility, clothing allowance) in the space provided.
Benefit Type — Additional Details	Text	Enter the specific benefit type details you are claiming (for example, if claiming a VHA benefit, specify Travel/Mileage Reimbursement, Medical Treatment Reimbursement, Health Care Eligibility, Clothing Allowance, or provide other relevant benefit details). Fill only if 'Veterans Health Administration' is 'Yes'.
Claimant Date of Birth
Claimant Date of Birth - Month	Text	Enter the claimant's month of birth as a two-digit number (MM). Max length: 2 characters
Claimant Date of Birth - Day	Text	Enter the claimant's day of birth as a two-digit number (DD). Max length: 2 characters
Claimant Date of Birth - Year	Text	Enter the claimant's year of birth as a four-digit number (YYYY). Max length: 4 characters
Claimant Email Address
Claimant Email Address	Text	Enter the claimant's email address (optional) so VA can contact the claimant about this claim, e.g., [email protected].
Claimant Mailing Address
Mailing Street Address (No. & Street)	Text	Enter the claimant's street address: house number and street name, rural route, or P.O. Box for the mailing address. Max length: 30 characters
Apt/Unit Number	Text	Enter the claimant's apartment, unit, suite, or other secondary address identifier, if applicable. Max length: 5 characters
City	Text	Enter the city for the claimant's mailing address. Max length: 18 characters
State or Province	Text	Enter the state, province, territory, or region for the claimant's mailing address. Max length: 2 characters
Country	Text	Enter the country name for the claimant's mailing address. Max length: 2 characters
ZIP/Postal Code	Text	Enter the primary ZIP code or postal code for the claimant's mailing address (for U.S. addresses, enter the five-digit ZIP). Max length: 5 characters
ZIP+4 / Postal Code Extension	Text	If applicable, enter the ZIP+4 4-digit extension for U.S. addresses or any additional postal code suffix; otherwise leave blank. Max length: 4 characters
Claimant Name
Claimant First Name	Text	Enter the claimant's given (first) name exactly as it appears on legal documents. Max length: 12 characters
Claimant Last Name	Text	Enter the claimant's family (last) name or surname exactly as it appears on legal documents. Max length: 18 characters
Claimant Middle Name or Initial	Text	Enter the claimant's middle name or middle initial; if none, leave this field blank. Max length: 1 characters
Claimant Relationship to Veteran
Relationship to Veteran — Other (Specify)	Text	If the claimant's relationship to the veteran is not listed among the checkboxes, enter the specific relationship (e.g., cousin, friend, power of attorney) in this field.
Spouse	Radiobutton	Check this box if the claimant is the veteran's spouse.
Child	Radiobutton	Check this box if the claimant is the veteran's child.
Fiduciary	Radiobutton	Check this box if the claimant is the veteran's fiduciary (person legally authorized to manage the veteran's affairs).
Parent	Radiobutton	Check this box if the claimant is the veteran's parent.
Other (Specify)	Radiobutton	Check this box if the claimant has a relationship to the veteran not listed above, and write the specific relationship in the space provided.
Claimant Social Security Number
Claimant SSN — Part 1 (First 3 digits)	Text	Enter the first three digits of the claimant's Social Security Number. Max length: 3 characters
Claimant SSN — Part 2 (Next 2 digits)	Text	Enter the middle two digits of the claimant's Social Security Number. Max length: 2 characters
Claimant SSN — Part 3 (Last 4 digits)	Text	Enter the last four digits of the claimant's Social Security Number. Max length: 4 characters
Claimant Telephone Number
Claimant Telephone Number - Prefix	Text	Enter the three-digit prefix (the first three digits after the area code) of the claimant's telephone number. Max length: 3 characters
Claimant International Phone Number	Text	If applicable, enter the claimant's full international phone number including the country code and any necessary international dialing prefix.
Claimant Telephone Number - Line Number	Text	Enter the four-digit line number (the last four digits) of the claimant's telephone number. Max length: 4 characters
Claimant Telephone Number - Area Code	Text	Enter the claimant's three-digit area code for the telephone number (include the area code even if calling within the same area). Max length: 3 characters
Claimant VA File Number
Claimant VA File Number	Text	Enter the claimant's VA file number (if applicable) exactly as it appears on VA records; include any letters or leading zeros. Max length: 9 characters
Claimant VA Insurance Policy Number
Claimant VA Insurance Policy Number	Text	Enter the claimant's VA insurance policy number as it appears on the claimant's VA insurance documents (enter letters and/or numbers exactly as shown). Max length: 18 characters
Date Last VA Form 21-22/21-22A Submitted (29D)
29D - Month	Text	Enter the month of the last date the VA Form 21-22 or 21-22A was submitted (the month portion of that date). Fill only if 'Benefit Type' is not 'LIFE INSURANCE'. Max length: 2 characters Depends on: Life Insurance
29D - Day	Text	Enter the day of the month of the last date the VA Form 21-22 or 21-22A was submitted (the day portion of that date). Fill only if 'Benefit Type' is not 'LIFE INSURANCE'. Max length: 2 characters Depends on: Life Insurance
29D - Year	Text	Enter the year of the last date the VA Form 21-22 or 21-22A was submitted (the year portion of that date). Fill only if 'Benefit Type' is not 'LIFE INSURANCE'. Max length: 4 characters Depends on: Life Insurance
Eighth Supplemental Issue (21A Specific Issue & 21B Decision Date)
Eighth - 21A Specific Issue(s)	Text	Enter the specific issue from the VA decision that you want VA to review as part of your eighth supplemental claim.
Eighth - 21B Date of VA Decision Notice (Month)	Date	Enter the month portion of the VA decision notice date for the issue listed in 21A. Max length: 2 characters
Eighth - 21B Date of VA Decision Notice (Day)	Date	Enter the day portion of the VA decision notice date for the issue listed in 21A. Max length: 2 characters
Eighth - 21B Date of VA Decision Notice (Year)	Date	Enter the year portion of the VA decision notice date for the issue listed in 21A. Max length: 4 characters
Fifth Supplemental Issue (21A Specific Issue & 21B Decision Date)
Fifth - 21A Specific Issue	Text	Enter the specific issue you want VA to review as part of your fifth supplemental claim (briefly describe the contested benefit, condition, or decision issue).
Fifth - 21B Decision Date (Month)	Date	Enter the month portion of the VA decision notice date associated with this specific issue. Max length: 2 characters
Fifth - 21B Decision Date (Day)	Date	Enter the day portion of the VA decision notice date associated with this specific issue. Max length: 2 characters
Fifth - 21B Decision Date (Year)	Date	Enter the year portion of the VA decision notice date associated with this specific issue. Max length: 4 characters
First Supplemental Issue (21A Specific Issue & 21B Decision Date)
First Supplemental Issue 21A: Specific Issue	Text	Provide a concise description of the specific issue decided by the VA that you want VA to review as part of this supplemental claim.
First Supplemental Issue 21B: Decision Date — Month	Date	Enter the month of the VA decision notice date for this issue. Max length: 2 characters
First Supplemental Issue 21B: Decision Date — Day	Date	Enter the day of the VA decision notice date for this issue. Max length: 2 characters
First Supplemental Issue 21B: Decision Date — Year	Date	Enter the year of the VA decision notice date for this issue. Max length: 4 characters
First Witness Printed Name and Address (26B)
26B First Witness Address	Text	Enter the first witness's complete mailing address (street, city, state, ZIP) as a single text string.
26B First Witness Printed Name	Text	Enter the first witness's full printed name as it should appear on the form.
Fourth Supplemental Issue (21A Specific Issue & 21B Decision Date)
Fourth - 21A Specific Issue(s)	Text	Enter the specific issue or issues decided by the VA that you want the VA to review as part of this fourth supplemental claim.
Fourth - 21B Decision Date (Month)	Date	Enter the month of the VA decision notice for the issue listed in 21A. Max length: 2 characters
Fourth - 21B Decision Date (Day)	Date	Enter the day of the month of the VA decision notice for the issue listed in 21A. Max length: 2 characters
Fourth - 21B Decision Date (Year)	Date	Enter the year of the VA decision notice for the issue listed in 21A. Max length: 4 characters
General
25. A. VETERAN/CLAIMANT'S SIGNATURE	Signature
SECTION 9: WITNESSES TO SIGNATURE. (NOTE: Only use this section if the veteran/claimant used an "X" in Item 25. A.) 26. A. SIGNATURE OF THE FIRST WITNESS. This is a digital signature	Signature
27. A. SIGNATURE OF SECOND WITNESS. This is a digital signature	Signature
SECTION 10: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (NOTE: REQUIRED ONLY IF ITEM 25. A. IS BLANK). 28. A. ALTERNATE SIGNER SIGNATURE. This is a digital signature	Signature
29. A. POA/AUTHORIZED REPRESENTATIVE'S SIGNATURE. (Required)	Signature
Ninth Supplemental Issue (21A Specific Issue & 21B Decision Date)
9th Supplemental Issue — 21A Specific Issue(s)	Text	Enter the description or title of the ninth specific issue you want VA to review as listed on the decision notice.
9th Supplemental Issue — 21B Decision Date (Month)	Text	Enter the month component of the VA decision notice date for the ninth issue. Max length: 2 characters
9th Supplemental Issue — 21B Decision Date (Day)	Text	Enter the day component of the VA decision notice date for the ninth issue. Max length: 2 characters
9th Supplemental Issue — 21B Decision Date (Year)	Text	Enter the year component of the VA decision notice date for the ninth issue. Max length: 4 characters
POA/Authorized Representative Accreditation Number (29C)
29C. POA/Authorized Representative Accreditation Number	Text	Enter the accreditation number issued to the power of attorney or authorized representative by the VA (the representative’s official accreditation ID). Fill only if 'Benefit Type' is not 'LIFE INSURANCE'. Depends on: Life Insurance
POA/Authorized Representative Date Signed (29B)
29B Date Signed — Month (MM)	Text	Enter the month the POA/authorized representative signed the form as a two-digit number (MM), e.g., 01 for January. Fill only if 'Benefit Type' is not 'LIFE INSURANCE'. Max length: 2 characters Depends on: Life Insurance
29B Date Signed — Day (DD)	Text	Enter the day of the month the POA/authorized representative signed the form as a two-digit number (DD), e.g., 05. Fill only if 'Benefit Type' is not 'LIFE INSURANCE'. Max length: 2 characters Depends on: Life Insurance
29B Date Signed — Year (YYYY)	Text	Enter the four-digit year the POA/authorized representative signed the form (YYYY), e.g., 2026. Fill only if 'Benefit Type' is not 'LIFE INSURANCE'. Max length: 4 characters Depends on: Life Insurance
Second Supplemental Issue (21A Specific Issue & 21B Decision Date)
Second Supplemental Issue 21A - Specific Issue(s)	Text	Enter the specific issue(s) you want the VA to review for this supplemental claim (briefly describe the condition(s) or benefit issue(s)).
Second Supplemental Issue 21B - Decision Date (Month)	Text	Enter the month of the VA decision notice for this issue as a two-digit month (MM). Max length: 2 characters
Second Supplemental Issue 21B - Decision Date (Day)	Text	Enter the day of the VA decision notice for this issue as a two-digit day (DD). Max length: 2 characters
Second Supplemental Issue 21B - Decision Date (Year)	Text	Enter the year of the VA decision notice for this issue as a four-digit year (YYYY). Max length: 4 characters
Second Witness Printed Name and Address (27B)
27B Second Witness Printed Name	Text	Enter the full printed name of the second witness as it should appear on the form.
27B Second Witness Address	Text	Enter the complete mailing address of the second witness (street, city, state, and ZIP) as a single text entry.
Section VI 5103 Notice Acknowledgement
YES	Radiobutton	Check this box if you have reviewed the 5103 Notice of Evidence that relates to your claim and you certify that you have reviewed it.
NO	Radiobutton	Check this box if you have NOT reviewed the 5103 Notice of Evidence (selecting No will prompt VA to send the 5103 notice to you by mail).
Section VII VBA Notification to VHA Consent Choice
Section VII — A. I CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENT(S) RELATED TO MY CLAIM AND/OR APPEAL	Radiobutton	Check this box if you give VBA permission to electronically notify VHA about certain upcoming events related to your claim or appeal so an indicator for those events will appear in your VHA medical record. Fill only if 'Benefit Type (COMPENSATION)' is 'Yes'. Depends on: Compensation
Section VII — B. I DO NOT CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENT(S) RELATED TO MY CLAIM AND/OR APPEAL	Radiobutton	Check this box if you do not want VBA to notify VHA about upcoming events related to your claim or appeal (an indicator for those events will not appear in your VHA medical record). Fill only if 'Benefit Type (COMPENSATION)' is 'Yes'. Depends on: Compensation
Section VII — C. I REVOKE PRIOR CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENT(S) RELATED TO MY CLAIM AND/OR APPEAL	Radiobutton	Check this box if you previously consented but now want to withdraw that consent so future notices of those events will no longer appear in your VHA medical record. Fill only if 'Benefit Type (COMPENSATION)' is 'Yes'. Depends on: Compensation
Section VII — D. NOT APPLICABLE AND/OR NOT ENROLLED OR REGISTERED IN VHA HEALTH CARE	Radiobutton	Check this box if the notification option does not apply to you because you are not enrolled or registered in VHA health care. Fill only if 'Benefit Type (COMPENSATION)' is 'Yes'. Depends on: Compensation
Seventh Supplemental Issue (21A Specific Issue & 21B Decision Date)
Seventh 21A Specific Issue	Text	Enter the specific VA issue you want reviewed as part of your seventh supplemental claim (a short description of the contested issue).
Seventh 21B Decision Date - Month	Date	Enter the month portion of the VA decision date for the issue listed in the corresponding Seventh 21A field. Max length: 2 characters
Seventh 21B Decision Date - Day	Date	Enter the day portion of the VA decision date for the issue listed in the corresponding Seventh 21A field. Max length: 2 characters
Seventh 21B Decision Date - Year	Date	Enter the year portion of the VA decision date for the issue listed in the corresponding Seventh 21A field. Max length: 4 characters
Sixth Supplemental Issue (21A Specific Issue & 21B Decision Date)
Sixth - 21A Specific Issue(s)	Text	Enter a concise, specific description of the issue you want VA to review for this supplemental claim (for example, the contested condition or benefit issue).
Sixth - 21B Decision Date (Month)	Text	Enter the month of the VA decision notice for this issue as a two-digit number (MM). Max length: 2 characters
Sixth - 21B Decision Date (Day)	Text	Enter the day of the VA decision notice for this issue as a two-digit number (DD). Max length: 2 characters
Sixth - 21B Decision Date (Year)	Text	Enter the year of the VA decision notice for this issue as a four-digit year (YYYY). Max length: 4 characters
Third Supplemental Issue (21A Specific Issue & 21B Decision Date)
Third Supplemental Issue 21A - Specific Issue(s)	Text	Enter the specific issue(s) you want the VA to review as part of this supplemental claim for this row, using a concise description of the contested decision.
Third Supplemental Issue 21B - Decision Date (Month)	Text	Enter the month of the VA decision notice date for the issue listed in 21A (use the numeric month for the decision). Max length: 2 characters
Third Supplemental Issue 21B - Decision Date (Day)	Text	Enter the day of the VA decision notice date for the issue listed in 21A (use the numeric day of month). Max length: 2 characters
Third Supplemental Issue 21B - Decision Date (Year)	Text	Enter the year of the VA decision notice date for the issue listed in 21A (use the four-digit year). Max length: 4 characters
Veteran Date of Birth
Date of Birth - Month	Text	Enter the veteran's birth month as a two-digit number (MM), e.g., 01 for January. Max length: 2 characters
Date of Birth - Day	Text	Enter the veteran's birth day as a two-digit number (DD), e.g., 05 for the fifth day of the month. Max length: 2 characters
Date of Birth - Year	Text	Enter the veteran's birth year as a four-digit number (YYYY), e.g., 1980. Max length: 4 characters
Veteran Email Address
Veteran Email Address	Text	Enter the veteran's primary email address where VA can send notifications and correspondence (e.g., [email protected]).
Veteran Mailing Address
Street Address (Number & Street)	Text	Enter the veteran's street number and street name, P.O. Box, or rural route used for mailing. Max length: 30 characters
Apt/Unit Number	Text	Enter the apartment, unit, suite, or other secondary address identifier for the mailing address, or leave blank if none. Max length: 5 characters
City	Text	Enter the city or locality for the veteran's mailing address. Max length: 18 characters
State/Province	Text	Enter the state or province for the mailing address (use the standard postal abbreviation if applicable). Max length: 2 characters
Country	Text	Enter the country for the veteran's mailing address (for U.S. addresses, enter United States or USA). Max length: 2 characters
ZIP/Postal Code	Text	Enter the primary ZIP or postal code for the mailing address (for U.S. ZIP codes, enter the first five digits). Max length: 5 characters
ZIP+4 or Postal Code Suffix	Text	Enter the ZIP+4 last four digits or any additional postal code suffix if applicable, otherwise leave blank. Max length: 4 characters
Veteran Name
First Name	Text	Enter the veteran's given (first) name as it appears on official records. Max length: 12 characters
Last Name	Text	Enter the veteran's family (last) name or surname as it appears on official records. Max length: 18 characters
Middle Initial	Text	Enter the veteran's middle initial (one letter) or leave blank if none. Max length: 1 characters
Veteran Service Number
Service Number	Text	Enter the veteran's service number assigned during military service as it appears on official military records. Max length: 10 characters
Veteran Social Security Number
Social Security Number — Part 1 (first 3 digits)	Text	Enter the first three digits of the veteran's Social Security Number as shown on their SSN card. Max length: 3 characters
Social Security Number — Part 2 (middle 2 digits)	Text	Enter the middle two digits of the veteran's Social Security Number. Max length: 2 characters
Social Security Number — Part 3 (last 4 digits)	Number	Enter the last four digits of the veteran's Social Security Number. Max length: 4 characters
Veteran Telephone Number
Veteran International Phone Number (If applicable)	Text	Enter the veteran's international phone number including country code, area code and local number if the number is outside the U.S.
Veteran Telephone — Prefix (exchange)	Text	Enter the three-digit telephone prefix/exchange that follows the area code. Max length: 3 characters
Veteran Telephone — Line Number	Text	Enter the four-digit subscriber line number (the final part of the telephone number). Max length: 4 characters
Veteran Telephone — Area Code	Text	Enter the veteran's three-digit telephone area code (include the area code even if optional). Max length: 3 characters
Veteran VA File Number
VA File Number	Text	Enter the veteran's VA file number as assigned by the Department of Veterans Affairs, including any letters, dashes, or leading zeros exactly as shown on VA correspondence. Max length: 9 characters
Veteran VA Insurance Policy Number
VA Insurance Policy Number	Text	Enter the veteran's full VA insurance policy number exactly as it appears on VA insurance documents or cards (include any letters, dashes, or other characters). Max length: 18 characters
Veteran/Claimant Date Signed (25B)
25B Month (Date Signed - Month)	Text	Enter the month the veteran/claimant signed the form as a two-digit month value (e.g., 01 for January). Max length: 2 characters
25B Day (Date Signed - Day)	Text	Enter the day of the month the veteran/claimant signed the form as a two-digit day value (e.g., 05). Max length: 2 characters
25B Year (Date Signed - Year)	Number	Enter the year the veteran/claimant signed the form. Max length: 4 characters

VA Form 20-0995, Decision Review Request: Supplemental Claim Instructions