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VA Form 21-10210: Lay/Witness Statement

VA Form 21-10210 is the standard form for a lay statement, often called a buddy statement, that you or a witness submits as evidence in support of a VA claim.

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What is VA Form 21-10210?

VA Form 21-10210, Lay/Witness Statement, captures firsthand written testimony in support of a VA claim. A claimant can use it to describe symptoms and events in their own words, and other people, such as fellow service members, family, friends, or coworkers, can use it to describe what they personally observed.

Lay evidence can help establish things that records alone may not show, like when symptoms started, how a condition affects daily life, or that an in-service event occurred. The statement is signed under a certification that it is true, and the form identifies both the claimant and the person making the statement.

Who files VA Form 21-10210?

Veterans writing a personal statement in support of their own claim
Fellow service members providing buddy statements about in-service events
Family members, friends, or coworkers describing observed symptoms or changes
Survivors and other claimants submitting witness statements for a VA benefit claim

How to fill out VA Form 21-10210

Enter the claimant's identifying information, and the witness's information if someone else is making the statement.
Write the statement in the space provided, sticking to facts the writer personally knows or observed.
Include relevant dates, places, and units where they help VA connect the statement to the claim.
Sign and date the certification.
Submit it online through 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 21-10210 on this page

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Page 1 50 fields

Read instructions above. SECTION 1: VETERAN'S IDENTIFICATION INFORMATION. Read Note above. 1. VETERAN'S NAME (First, Middle Initial, Last).

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

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

2. SOCIAL SECURITY NUMBER. Enter First Three Digits.

2. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

2. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

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

4. DATE OF BIRTH. Enter 2 digit Month.

4. DATE OF BIRTH. Enter 2 digit day.

4. DATE OF BIRTH. Enter 4 digit year.

5. V. A. INSURANCE FILE NUMBER (If applicable). 20 characters max.

6. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country). Number and Street. 30

6. CURRENT MAILING ADDRESS. Apartment or Unit Number. 5 characters max.

6. CURRENT MAILING ADDRESS. City. 18 characters max.

6. CURRENT MAILING ADDRESS. State or Province. 2 characters max.

6. CURRENT MAILING ADDRESS. Country. 2 characters max.

6. CURRENT MAILING ADDRESS. ZIP or Postal Code. First 5 digits.

6. CURRENT MAILING ADDRESS. ZIP or Postal Code. Last 4 digits.

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

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

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

7. Enter International Phone Number (If applicable).

8. I agree to receive electronic correspondence from V. A. in regards to my claim.

8. E-MAIL ADDRESS. 20 characters max. Line 1 of 2.

8. E-MAIL ADDRESS. 20 characters max. Line 2 of 2.

SECTION 2: CLAIMANT'S IDENTIFICATION INFORMATION (Complete this section ONLY IF the claimant is NOT the veteran). 9. CLAIMANT'S NAME

9. CLAIMANT'S NAME. Middle Initial. 1 character max.

9. CLAIMANT'S NAME. Last Name. 18 characters max.

10. SOCIAL SECURITY NUMBER. Enter First Three Digits.

10. SOCIAL SECURITY NUMBER. Enter Middle Two Digits.

10. SOCIAL SECURITY NUMBER. Enter Last Four Digits.

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

12. DATE OF BIRTH. Enter 2 digit Month.

12. DATE OF BIRTH. Enter 2 digit day.

12. DATE OF BIRTH. Enter 4 digit year.

13. V. A. INSURANCE FILE NUMBER (If applicable). 20 characters max.

14. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country). Number and Street. 30

14. CURRENT MAILING ADDRESS. Apartment or Unit Number. 5 characters max.

14. CURRENT MAILING ADDRESS. City. 18 characters max.

14. CURRENT MAILING ADDRESS. State or Province. 2 characters max.

14. CURRENT MAILING ADDRESS. Country. 2 characters max.

14. CURRENT MAILING ADDRESS. ZIP or Postal Code. First 5 digits.

14. CURRENT MAILING ADDRESS. ZIP or Postal Code. Last 4 digits.

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

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

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

15. Enter International Phone Number (If applicable).

16. I agree to receive electronic correspondence from V. A. in regards to my claim.

16. E-MAIL ADDRESS. 20 characters max. Line 1 of 2.

16. E-MAIL ADDRESS. 20 characters max. Line 2 of 2.

Page 2 1 fields

SECTION 3: STATEMENT (Use this section to submit your statement, or a statement from someone else writing on your behalf). Read Note above.

Page 3 18 fields

SECTION 3: STATEMENT (Continued). (Use this section to submit your statement, or a statement from someone else writing on your behalf).

SECTION 4: WITNESS CONTACT INFORMATION (Complete Section 4 and 5 if the statement in Section 3 is from someone else writing on your

18. WITNESS NAME. Middle Initial. 1 character max.

18. WITNESS NAME. Last Name. 18 characters max.

19. RELATIONSHIP TO VETERAN / CLAIMANT (Check all that apply). SERVED WITH VETERAN / CLAIMANT.

19. FAMILY / FRIEND OF VETERAN / CLAIMANT.

19. COWORKER / SUPERVISOR OF VETERAN / CLAIMANT.

19. OTHER (Specify).

19. Specify Other. 30 characters max.

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

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

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

20. Enter International Phone Number (If applicable).

21. E-MAIL ADDRESS. 20 characters max. Line 1 of 2.

21. E-MAIL ADDRESS. 20 characters max. Line 2 of 2.

22. B. DATE SIGNED. Enter 2 digit Month.

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

22. B. DATE SIGNED. Enter 4 digit year.

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Frequently asked questions

What makes a strong buddy statement?

Specific, firsthand facts: what the writer saw or experienced, when and where it happened, and how the condition affected the claimant. Opinions on medical diagnosis carry little weight from a lay witness; observations do.

Do I have to use this exact form?

VA accepts lay statements in other written formats, but VA Form 21-10210 is the standard form and includes the certification VA looks for, which makes processing simpler.

VA Form 21-10210: Lay/Witness Statement

What is VA Form 21-10210?

Who files VA Form 21-10210?

How to fill out VA Form 21-10210

Quick fill VA Form 21-10210 on this page

Frequently asked questions

Related forms

VA Form 21-4138: Statement in Support of Claim

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

VA Form 21-526EZ, Application for Disability Compensation