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VA Form 21-0781: Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s)

VA Form 21-0781 lets you describe the traumatic events from your military service that relate to a claimed mental health condition, helping VA find the records that support your claim.

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What is VA Form 21-0781?

VA Form 21-0781, Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s), supports disability compensation claims for PTSD and other mental health conditions connected to traumatic events during service, including combat, personal assault or harassment, accidents, and other experiences.

VA consolidated its earlier PTSD statement forms, including the separate personal assault form 21-0781a, into this single form. It asks about the events, when and where they happened, units involved, and possible sources of supporting evidence, including behavioral changes for claims based on personal trauma. Completing it is optional but helps VA locate corroborating records.

Who files VA Form 21-0781?

Veterans claiming disability compensation for PTSD related to in-service events
Veterans claiming other mental health conditions, such as depression or anxiety, connected to in-service trauma
Survivors of military sexual trauma or personal assault documenting events and markers
Claimants asked by VA to provide event details to support a pending mental health claim

How to fill out VA Form 21-0781

Enter your identifying information and the mental health condition(s) you are claiming.
Describe each traumatic event, including the approximate date, location, and unit assignment at the time.
For personal trauma claims, note any sources of evidence and behavioral changes that followed the events.
Sign and date the form.
Submit it with your claim online at va.gov, upload it to a pending claim, or mail it to the VA Claims Intake Center address in the form instructions.

Quick fill VA Form 21-0781 on this page

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Page 3 29 fields

Read Important Note and Instructions above. SECTION 1: VETERAN/SERVICE MEMBER'S IDENTIFICATION INFORMATION. Read Note above. 1. VETERAN'S

3. V. A. FILE NUMBER (If applicable). Enter 9 digit file number.

1. VETERAN'S NAME. Last Name. 18 characters max.

1. VETERAN'S NAME. Middle Initial. 1 character max.

5. VETERAN'S SERVICE NUMBER (If applicable).

6. Enter International Phone Number (If applicable).

2. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

2. SOCIAL SECURITY NUMBER. Enter First Three Digits.

2. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

4. DATE OF BIRTH. Enter 2 digit Month.

4. DATE OF BIRTH. Enter 2 digit day.

4. DATE OF BIRTH. Enter 4 digit year.

6. TELEPHONE NUMBER (Include Area Code). Enter middle three digits.

6. TELEPHONE NUMBER (Include Area Code). Enter last four digits.

6. TELEPHONE NUMBER (Include Area Code). Enter three digits of Area Code.

SECTION 2: TRAUMATIC EVENT(S) INFORMATION. 8. SELECT THE TYPE OF IN-SERVICE TRAUMATIC EVENT(S) YOU EXPERIENCED. (Check more than one, if

8. Check box. Personal Traumatic Event(s) (not involving military sexual trauma (MST).

8. Check box. Personal Traumatic Event(s) (involving military sexual trauma (MST) (if checked review Section 6).

8. Check box. Other Traumatic Events.

9. A. BRIEF DESCRIPTION OF THE TRAUMATIC EVENT(S) (e.g., injury in warfare, physical assault, sexual harassment, witnessed the death or

9. B. LOCATION OF THE TRAUMATIC EVENT(S) (e.g., unit assignment, residence, off-base, duty station or state, if known). Line 1 of 5.

9. C. DATE(S) THE TRAUMATIC EVENT(S) OCCURED (e.g., month(s) or year(s), if known, or approximate dates are acceptable). Line 1 of 5.

9. C. DATE(S) THE TRAUMATIC EVENT(S) OCCURED (e.g., month(s) or year(s), if known, or approximate dates are acceptable). Line 2 of 5.

9. C. DATE(S) THE TRAUMATIC EVENT(S) OCCURED (e.g., month(s) or year(s), if known, or approximate dates are acceptable). Line 3 of 5.

9. B. LOCATION OF THE TRAUMATIC EVENT(S) (e.g., unit assignment, residence, off-base, duty station or state, if known). Line 2 of 5.

9. B. LOCATION OF THE TRAUMATIC EVENT(S) (e.g., unit assignment, residence, off-base, duty station or state, if known). Line 3 of 5.

7. E-Mail Address (Optional).

Page 4 29 fields

Page 5 31 fields

Page 6 20 fields

13. E. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT. Line 1 of 3.

13. D. DATE(S) OF TREATMENT. Enter 4 digit year.

13. D. DATE(S) OF TREATMENT. Enter 2 digit Month.

13. C. NAME AND LOCATION OF THE TREATMENT FACILITY. Line 1 of 3.

13. C. NAME AND LOCATION OF THE TREATMENT FACILITY. Line 2 of 3.

13. C. NAME AND LOCATION OF THE TREATMENT FACILITY. Line 3 of 3.

13. E. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT. Line 1 of 3.

13. D. DATE(S) OF TREATMENT. Enter 4 digit year.

13. D. DATE(S) OF TREATMENT. Enter 2 digit Month.

13. E. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT. Line 1 of 3.

13. D. DATE(S) OF TREATMENT. Enter 4 digit year.

13. D. DATE(S) OF TREATMENT. Enter 2 digit Month.

SECTION 5: REMARKS. Note: This section is optional and can be left blank. However, if additional space is needed to fully answer a previous

SECTION 6: OPTION FRO VETERANS BENEFIT ADMINISTRATION (VBA) TO NOTIFY VETERANS HEALTH ADMINISTRATION (VHA) ABOUT CERTAIN UPCOMING EVENTS

15. B. Check box. I DO NOT CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL (Note: I

15. C. Check box. I REVOKE PRIOR CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL (Note: I

15. D. Check box. NOT APPLICABLE AND/OR NOT ENROLLED OR REGISTERED IN VHA HEALTHCARE.

16. B. DATE SIGNED. Enter 2 digit month.

16. B. DATE SIGNED. Enter 2 digit day.

16. B. DATE SIGNED. Enter 4 digit Year.

Page 7 12 fields

17. B. Printed Name and Address of Witness.

18. B. Printed Name and Address of Witness.

19. B. DATE SIGNED. Enter 2 digit month.

19. B. DATE SIGNED. Enter 2 digit day.

19. B. DATE SIGNED. Enter 4 digit Year.

20. B. DATE SIGNED. Enter 2 digit month.

20. B. DATE SIGNED. Enter 2 digit day.

20. B. DATE SIGNED. Enter 4 digit Year.

20. D. DATE LAST VA FORM 21-22 OR VA FORM 21-22A WAS SUBMITTED (If known). Enter 2 digit month.

20. B. DATE SIGNED. Enter 2 digit day.

20. B. DATE SIGNED. Enter 4 digit Year.

20. C. ACCREDITATION NUMBER.

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Frequently asked questions

Do I have to use VA Form 21-0781?

No, it is optional. But the details it collects help VA request the right unit records and other evidence to corroborate the events, which can make a real difference in a PTSD or other mental health claim.

What happened to VA Form 21-0781a?

VA discontinued the separate personal assault statement form and folded its content into the current VA Form 21-0781, which now covers all claimed in-service traumatic events, including sexual assault and harassment.

What if I cannot remember exact dates?

Give your best approximation, such as a month range and year, along with location and unit. Approximate windows are usually enough for VA to search unit and incident records.

VA Form 21-0781: Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s)

What is VA Form 21-0781?

Who files VA Form 21-0781?

How to fill out VA Form 21-0781

Quick fill VA Form 21-0781 on this page

Frequently asked questions

Related forms

VA Form 21-526EZ, Application for Disability Compensation

VA Form 21-4138: Statement in Support of Claim

VA Form 21-10210: Lay/Witness Statement