VA Form 20-10206 FOIA

Section 1 of 12

About You (Section I, Items 1 to 6)

Complete this if you are requesting records on yourself. For Privacy Act requests, full name, date of birth, place of birth, mailing address, and signature are required.

1. Name (First, Middle Initial, Last): *

2. Social Security Number:

3. Alien Registration Number (if applicable):

4. VA File Number (if applicable):

5. Date of Birth:

6. Place of Birth: City and State, County and State, or City and Country.

Section 2 of 12

Your Contact Information (Section I, Items 7 to 9)

7. Number and Street (or P.O. Box):

Apt./Unit Number:

City:

State/Province:

Country:

ZIP Code/Postal Code:

8A. Telephone Number:

International Phone (if applicable):

8B. Fax Number (if applicable):

International Fax (if applicable):

9. E-mail Address:

I agree to receive electronic correspondence from VA.

Section 3 of 12

Requester (Section II, Items 10 to 12)

Complete only if you are requesting records about a person other than yourself. Otherwise leave blank.

10. Your Name or Your Organization's Name:

11. Number and Street (or P.O. Box):

Apt./Unit Number:

City:

State/Province:

Country:

ZIP Code/Postal Code:

12A. Telephone Number:

12B. Fax Number (if applicable):

Section 4 of 12

Subject of Request (Section II, Items 13 to 16)

Complete Items 13 to 16 to tell VA whom the request is about. Only needed for requests on a person other than yourself.

13. Name of the Person You Are Requesting Information On:

14. Social Security Number:

15. Alien Registration Number (if applicable):

16. VA File Number (if applicable):

Section 5 of 12

Compensation and Pension Records (Section III, Item 17)

Select the type(s) of records you are requesting.

Claims File (C-File) Service Treatment Records / Military Treatment Records DD Form 214 Disability Examinations (C & P Exams) Pension Benefit Documents Official Military Personnel File (OMPF) Other

For C & P Exams, enter the date of exam in Remarks (Section 8) if applicable.

Section 6 of 12

Other Records Request (Section IV, Item 18)

Describe any records you are requesting that are not covered in Section 5. Leave blank if not applicable.

18. Description of Records Requested:

Section 7 of 12

VA Regional Office (Section V, Item 19)

If known.

19. Name of VA Regional Office You Are Associated With:

Section 8 of 12

Remarks (Section VI, Item 20)

20. Remarks (if any):

Section 9 of 12

Willingness to Pay Fees (Section VII, Item 21)

FOIA may charge fees for search, review, and photocopying depending on requester category. VA charges $0.15 per single-sided page. An agency may grant a fee waiver if disclosure is in the public interest.

I am willing to pay the applicable fees up to the amount of:

I believe I am entitled to a fee waiver or expedited processing.

Section 10 of 12

Requester Certification and Signature (Section VIII)

I certify that I have completed this FOIA/PA request and declare it is true and correct to the best of my knowledge and belief.

22A. Requester's Signature (type full legal name): * Typing your full name here acts as your electronic signature.

22B. Date Signed: *

Section 11 of 12

Third-Party Certification (Section IX)

Valid only if Section 3/4 (request on another person) is completed and the requester has an authorized third party. A third-party signature is not accepted unless a valid VA Form 21-0845 is on file or attached. Leave blank if not applicable.

23A. Third-Party Signature (type full legal name):

23B. Date Signed:

Section 12 of 12

Power of Attorney Certification (Section X)

Valid only if Section 3/4 is completed and the requester has authorized POA representation. A POA signature is not accepted unless a valid VA Form 21-22 or 21-22a is on file or attached. Leave blank if not applicable.

24A. POA / Authorized Representative Signature (type full legal name):

24B. Date Signed: