Statement in Support of Claim Example and PDF

Many veterans learn best by seeing a real example. This guide gives you a full worked Statement in Support of Claim, shows where to download the official PDF, and walks through how to fill it out and submit it. Use the examples as a model for structure and detail, and write your own version with your real facts, since the VA weighs statements by how specific and credible they are.

01
What the Statement Is

The Statement in Support of Claim, VA Form 21-4138, is a general-purpose form where you write your own account to support your claim. It is lay evidence, meaning your first-hand testimony, and it can supply detail that official records do not contain. It is often used to describe an undocumented in-service event or to explain how a condition affects you.

02
Where to Get the Official PDF

Always use the official form rather than an unofficial copy. You can:

• Download the current PDF from the VA forms page on VA.gov
• Complete it online through your VA.gov account
• Confirm you have the latest version, since forms are updated periodically
• Avoid third-party sites that charge for the free form

03
The Parts of a Strong Statement

04
A Full Worked Example

Here is a complete example for a lower back claim: "This statement supports my claim for a lower back condition. In August 1996, while stationed at Fort Example, I injured my back lifting equipment during a field exercise. I was treated at the aid station and returned to duty, but no formal record was created. Since then I have had daily lower back pain that has gradually worsened. Today I cannot stand for more than 20 minutes, I wake at night from the pain, and I had to leave a warehouse job because I could no longer lift. I certify that this statement is true and correct to the best of my knowledge." This example names the condition, gives the date and place, notes the missing record, and describes concrete present-day impact.

05
Example: Increased Rating

For an increased rating, you might write: "This statement supports my request for an increased rating for my service-connected knee condition. Over the past two years my symptoms have worsened. I now use a brace daily, my knee gives out on stairs, and I take pain medication most days. I can no longer walk more than a block without stopping." This focuses on how the condition has become more severe since your last rating.

06
Example: Secondary Condition

For a secondary condition, you might write: "This statement supports my claim that my depression is secondary to my service-connected chronic pain. Since my back condition worsened, I have withdrawn from activities, struggle with low mood most days, and have difficulty sleeping. The constant pain has directly affected my mental health." This links a new condition to an already service-connected one.

07
How to Fill Out the Form

• Enter your identifying information at the top
• Note the claimed issue you are addressing
• Write your statement in the space provided
• Sign and date the certification

08
Using an Addendum for More Space

If your statement runs longer than the space on the form, you can attach an addendum with additional pages. Note on the form that an addendum is attached, and label each page with your name and the claimed issue. This lets you tell your full story without cramming it into a small box.

09
When to Use 21-10210 Instead

Use Form 21-4138 for your own statement. If someone else is writing on your behalf, such as a fellow service member, spouse, or friend, the VA prefers Form 21-10210, the Lay/Witness Statement, and each additional witness uses a separate form. Both forms are accepted, so the choice comes down to who is writing.

10
How to Submit It

• Upload it on VA.gov with your claim or afterward
• Submit it through your accredited representative
• Mail it to the Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444
• Keep a copy for your own records

11
Mistakes to Avoid

• Copying an example word for word instead of using your own facts
• Being vague with no dates, places, or specifics
• Making medical conclusions you are not qualified to reach
• Forgetting to sign and date the statement
• Paying a third party for the free official form

12
Frequently Asked Questions

VA Claims US Editorial Team

vaclaims.us

The VA Claims US editorial team is dedicated to helping veterans and their families understand and navigate the VA disability system. Our content is reviewed for accuracy against current VA regulations and updated whenever rates or policies change. Have a question? Contact us here.