VA FORM NOV 2017 21-4193
OMB Approved No. 2900-0116 Respondent Burden: 15 minutes
Expiration Date: 09-30-2020
EXISTING STOCK OF VA FORM 21-4193, JUN 2014, WILL BE USED.
NOTE: Pursuant to Title 38, U.S.C., 1505, 3482, 3680 and 5313,
awards of Department of Veterans Affairs benefits for veterans and
beneficiaries are subject to adjustment or discontinuance while
such persons are incarcerated. See Page 3 for information on how to
submit this form.
8. DATE OFFENSE WAS COMMITTED (MM/DD/YYYY)
NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR
BENEFICIARY INCARCERATED IN PENAL INSTITUTION
TO FROM
9. TYPE OF OFFENSE FOR WHICH COMMITTED 10. DATE OF CONFINEMENT
FOLLOWING CONVICTION (MM/DD/YYYY)
11. LENGTH OF SENTENCE 12. SCHEDULED RELEASE DATE
(MM/DD/YYYY)
MISDEMEANOR
13A. IS INDIVIDUAL IN A WORK RELEASE OR HALFWAY HOUSE
PROGRAM?
FELONY
13B. DATE ENTERED PROGRAM (MM/DD/YYYY)
NOYES
NAME AND ADDRESS OF INSTITUTION
2. VETERAN/BENEFICIARY's NAME (First, Middle Initial, Last)
NOTE: You can either complete the form online or by hand. Please
print the information requested in ink, neatly, and legibly to help
process the form.
3. SOCIAL SECURITY NUMBER
SECTION I: IDENTIFICATION INFORMATION
4. VA FILE NUMBER 5. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
6. VETERAN'S SERVICE NUMBER (If applicable) 7. RELATIONSHIP TO
VETERAN
SECTION II: INFORMATION ABOUT INCARCERATION
VA DATE STAMP (DO NOT WRITE IN THIS SPACE)
SECTION III: REMARKS
Month Day Year
YearDayMonth
YearDayMonthYearDayMonth
YearDayMonth
Page 1
Where to Send Your Written Correspondence
VA FORM 21-4193, NOV 2017 Page 3
These addresses serve all United States and foreign
locations.
COMPENSATION CLAIMS PENSION & SURVIVORS BENEFIT CLAIMS
Department of Veterans Affairs Evidence Intake Center
PO Box 4444 Janesville, WI 53547-4444
Department of Veterans Affairs Pension Intake Center
PO Box 5365 Janesville, WI 53547-5365
FIDUCIARY
Department of Veterans Affairs Fiduciary Intake
PO Box 95211 Lakeland, FL 33804-5211
BOARD OF VETERANS' APPEALS
Department of Veterans Affairs Board of Veterans' Appeals
PO Box 27063 Washington, DC 20038
Documents may be submitted by mail, in person at a VA regional
office or electronically. However, VA recommends submitting
correspondence electronically as this is the fastest method of
receipt. VA provides several tools to assist in electronic
submission. To learn more about how to submit documents and claims
electronically, visit
www.va.gov/disability/upload-supporting-evidence. You can also go
directly to access.va.gov to digitally upload any correspondence
using Direct Upload. By visiting www.va.gov you can also check your
claims status and learn about other VA benefits. If you need
assistance, you can find a local, accredited representative at
https://www.benefits.va.gov/vso/. If you prefer to mail your
correspondence, please use the related mailing address below.
www.va.gov/disability/upload-supporting-evidenceaccess.va.govwww.va.govhttps://www.benefits.va.gov/vso/
\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg
Department of Veterans Affairs Logo.
VA FORMNOV 2017
21-4193
OMB Approved No. 2900-0116Respondent Burden: 15 minutes
Expiration Date: 09-30-2020
EXISTING STOCK OF VA FORM 21-4193, JUN 2014,WILL BE USED.
NOTE: Pursuant to Title 38, U.S.C., 1505, 3482, 3680 and 5313,
awards of Department of Veterans Affairs benefits for veterans and
beneficiaries are subject to adjustment or discontinuance while
such persons are incarcerated. See Page 3 for information on
how
to submit this form.
8. DATE OFFENSE WAS COMMITTED (MM/DD/YYYY)
NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR
BENEFICIARY INCARCERATED IN PENAL INSTITUTION
TO
FROM
9. TYPE OF OFFENSE FOR WHICH COMMITTED
10. DATE OF CONFINEMENT FOLLOWING
CONVICTION (MM/DD/YYYY)
11. LENGTH OF SENTENCE
12. SCHEDULED RELEASE DATE (MM/DD/YYYY)
MISDEMEANOR
13A. IS INDIVIDUAL IN A WORK RELEASE OR HALFWAY HOUSE
PROGRAM?
FELONY
13B. DATE ENTERED PROGRAM (MM/DD/YYYY)
NO
YES
NAME AND ADDRESS OF INSTITUTION
2. VETERAN/BENEFICIARY's NAME (First, Middle Initial,
Last)
NOTE: You can either complete the form online or
by hand. Please print the information requested in ink,
neatly, and legibly to help process the form.
3. SOCIAL SECURITY NUMBER
SECTION I: IDENTIFICATION INFORMATION
4. VA FILE NUMBER
5. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
6. VETERAN'S SERVICE NUMBER (If applicable)
7. RELATIONSHIP TO VETERAN
SECTION II: INFORMATION ABOUT INCARCERATION
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)
SECTION III: REMARKS
Month
Day
Year
Year
Day
Month
Year
Day
Month
Year
Day
Month
Year
Day
Month
Page 1
M:\Pam_Ward\VBA-Internal\WIP\VBA-21-4193.xft
Pamela Ward
FF99 3.1
Electronic Forms
VBA-21-4193
{CF3222A7-20FA-11D4-ABC1-00D0B71D6ABB}
FormClient
Spelling
Checker;{224F7DEA-B7C1-11D3-AB40-00902712A5C9};PLSSpeller.cab
IAI
21-4193(6-04)
Pamela Ward
Electronic Forms
IAI
VA Form 21-4193
FF99 3.1
NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR
BENEFICIARY INCARCERATED IN PENAL INSTITUTION
RESPONDENT BURDEN: We need this information to determine the
adjustment or discontinuance of VA benefits for veterans and
beneficiaries who are incarcerated. Title 38, United States Code
1505, 3482, 3680, and 5313, allows us to ask for this information.
We estimate that you will need an average of 15 minutes to review
the instructions, find the information, and complete this form. VA
cannot conduct or sponsor a collection of information unless a
valid OMB control number is displayed. You are not required to
respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB
Internet Page at http:www.reginfo.gov/public/do/PRAMain. If
desired, you can call 1-800-827-1000 to get information on where to
send comments or suggestions about this form.
PRIVACY ACT INFORMATION: 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.
Information submitted is subject to verification through computer
matching programs with other agencies.
15. DATE SIGNED (MM/DD/YYYY)
14. NAME AND TITLE OF INSTITUTIONAL OFFICIAL
16. SIGNATURE OF INSTITUTIONAL OFFICIAL (Sign in ink)
SECTION IV: SIGNATURE OF OFFICIAL
17. INSTITUTION TELEPHONE NUMBER
(Include Area Code)
VA FORM 21-4193, NOV 2017
REMARKS (Continued)
VETERAN'S SOCIAL SECURITY NO.
Page 2
Where to Send Your Written Correspondence
VA FORM 21-4193, NOV 2017
Page 3
These addresses serve all United States and foreign
locations.
NOTE: As long as this appointment is in effect the organization
named herein will be recognized as the sole agent for presentation
of your claim before the Department of Veterans Affairs in
connection with your claim or any portion thereof.
COMPENSATION CLAIMS
PENSION & SURVIVORS BENEFIT CLAIMS
Department of Veterans Affairs
Evidence Intake Center
PO Box 4444
Janesville, WI 53547-4444
Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365
FIDUCIARY
Department of Veterans Affairs
Fiduciary Intake
PO Box 95211
Lakeland, FL 33804-5211
BOARD OF VETERANS' APPEALS
Department of Veterans Affairs
Board of Veterans' Appeals
PO Box 27063
Washington, DC 20038
Documents may be submitted by mail, in person at a VA regional
office or electronically. However, VA recommends submitting
correspondence electronically as this is the fastest method of
receipt.
VA provides several tools to assist in electronic submission. To
learn more about how to submit documents and
claims electronically,
visit www.va.gov/disability/upload-supporting-evidence. You
can also go directly to
access.va.gov to digitally upload any correspondence using
Direct Upload.
By visiting www.va.gov you can also check your claims
status and learn about other VA benefits.
If you need assistance, you can find a local, accredited
representative at https://www.benefits.va.gov/vso/.
If you prefer to mail your correspondence, please use the
related mailing address below.
NOTE: As long as this appointment is in effect the organization
named herein will be recognized as the sole agent for presentation
of your claim before the Department of Veterans Affairs in
connection with your claim or any portion thereof.
9. TYPE OF OFFENSE FOR WHICH COMMITTED. FELONY.: 09.
MISDEMEANOR.: 011. LENGTH OF SENTENCE.: 13. A. IS INDIVIDUAL IN A
WORK RELEASE OR HALFWAY HOUSE PROGRAM? YES.: 013. A. NO.: 0SECTION
3: REMARKS (Continued).: NOTE: Pursuant to Title 38, U.S.C., 15 05,
34 82, 36 80 and 53 13, awards of Department of Veterans Affairs
benefits for veterans and beneficiaries are subject to adjustment
or discontinuance while such persons are incarcerated. TO.: 2.
VETERAN / BENEFICIARY's NAME. Last Name. 18 characters available.:
2. VETERAN / BENEFICIARY's NAME. Middle Initial. 1 character
available.: SECTION 1: IDENTIFICATION INFORMATION. NOTE: You can
either complete the form online or by hand. Please print the
information requested in ink, neatly, and legibly to help process
the form. 2. VETERAN / BENEFICIARY's NAME. First Name. 12
characters available.: 3. Social Security Number. Enter last four
numbers.: 3. Social Security Number. Enter middle two numbers.: 3.
Social Security Number. Enter first three numbers.: 4. V. A. File
Number. Enter nine digit file number.: 13B. DATE ENTERED PROGRAM.
Enter 4 digit Year.: 13B. DATE ENTERED PROGRAM. Enter 2 digit Day.:
13B. DATE ENTERED PROGRAM. Enter 2 digit Month. : 6. Veteran's
Service Number (If applicable). Enter 9 digits.: 7. RELATIONSHIP TO
VETERAN.: 17. INSTITUTION TELEPHONE NUMBER (Include Area Code).:
Veteran's Social Security Number. Enter Last Four Digits.:
Veteran's Social Security Number. Enter Middle Two Digits.:
Veteran's Social Security Number. Enter First Three Digits.: 15.
DATE SIGNED. Enter 2-digit month, 2-digit day and 4-digit
year.:
