Veterans Affairs Claims Form

VETERANS AFFAIRS CLAIMS FORM

Parties and Identification

Claimant Name:    VA File Number or SSN:

WHEREAS (Recitals)

WHEREAS, Claimant is a veteran or dependent asserting entitlement to benefits, compensation, or other relief administered through the Department of Veterans Affairs; and

WHEREAS, Claimant desires to retain Representative to prepare, submit, and pursue the identified claim(s) on Claimant's behalf and to obtain and authorize the release of records necessary to support the claim; and

WHEREAS, Representative agrees to act on Claimant's behalf subject to the terms and conditions set forth below.

Scope of Work

The Representative will perform the following services on behalf of Claimant (select applicable and describe any special instructions):

Services may include: initial claim filing, supplemental claims, appeals, scheduling and preparing for hearings, obtaining medical and service records, and corresponding with VA adjudicators and medical examiners.

Claim Details

Disability Compensation    Pension    Dependency & Indemnity Compensation    Other

Branch:    From (MM/DD/YYYY):    To (MM/DD/YYYY):

Evidence and Authorization

Claimant authorizes Representative to obtain medical, service, and employment records and to communicate with health care providers, the Department of Veterans Affairs, and other third parties as necessary to support the claim.

DD Form 214 or separation documents    Service medical records    Private medical records    Employment/earnings records

Payment Terms

Claimant agrees to compensate Representative according to the terms below. Representative will provide an itemized statement of fees and expenses upon request.

Fee Type: Hourly    Flat Fee    Contingency

If contingency fee is selected, specify percentage of past-due benefits to be charged and whether court approval is required:

Term and Termination

This Agreement commences on the Effective Date and continues until the conclusion of the claim, unless earlier terminated as provided below.

Effective Date:    Estimated End Date (if any):

Either party may terminate this Agreement for material breach or upon provision of written notice in accordance with the notice period above. Termination does not relieve Claimant’s obligation to pay for services performed and costs incurred prior to termination.

Confidentiality

Representative shall maintain the confidentiality of Claimant’s non-public information and shall use such information solely for purposes of pursuing the claim. This confidentiality obligation does not apply to information that is public, independently developed, or required to be disclosed by law or by VA regulation.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state of , without regard to choice-of-law principles that would apply the laws of any other jurisdiction.

Representations, Warranties and Certifications

Claimant certifies under penalty of perjury that the information provided in this form is true and correct to the best of Claimant’s knowledge. Claimant authorizes the release of records and information necessary to support the claim and further authorizes Representative to act on Claimant’s behalf as specified herein.

Entire Agreement

This document, together with any attached written fee schedules or exhibits signed by both parties, constitutes the entire agreement between Claimant and Representative with respect to the subject matter herein and supersedes all prior or contemporaneous agreements and understandings, whether oral or written.

Consent to Release Records and Acknowledgement

By signing below, Claimant authorizes Representative to obtain and review records relevant to the claim and acknowledges receipt of a copy of this Agreement. Claimant understands that fees may be charged as provided above and that Representative will maintain appropriate confidentiality and compliance with applicable privacy laws.

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