Form VBA-21-4193 NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR B

OMB Approved No. 2900-0116
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX
VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

NOTICE TO DEPARTMENT OF VETERANS AFFAIRS OF VETERAN OR
BENEFICIARY INCARCERATED IN PENAL INSTITUTION
NOTE: Pursuant to Title 38, U.S.C., 1505, 3482, 3680 and 5313, awards of Department of
Veterans Affairs benefits for veterans and beneficiaries are subject to adjustment or
discontinuance while such persons are incarcerated. See Page 3 for information on how
to submit this form.
NAME AND ADDRESS OF INSTITUTION

FROM

TO

SECTION I: VETERAN/BENEFICIARY IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, and insert one
letter per box, to help expedite processing of the form.
2. VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last)

4. VA FILE NUMBER

3. SOCIAL SECURITY NUMBER

5. VETERAN'S DATE OF BIRTH
Day

Month

6. VETERAN'S SERVICE NUMBER (If applicable)

Year

7. RELATIONSHIP TO VETERAN (If other than veteran)

SECTION II: INCARCERATION INFORMATION
9. TYPE OF OFFENSE FOR WHICH COMMITTED

8. DATE OFFENSE WAS COMMITTED
Month

Day

Year

Day

INFRACTION

MISDEMEANOR

10B. DATE OF CONFINEMENT FOLLOWING CONVICTION

10A. DATE OF CONVICTION
Month

FELONY

Year

11A. LENGTH OF SENTENCE

11B. HAS/WILL INCARCERATION LAST(ED) MORE THAN
60 DAYS FOLLOWING DATE OF CONVICTION?
YES

12. SCHEDULED RELEASE DATE
Day

Month

Year

NO

13A. IS INDIVIDUAL IN A WORK RELEASE OR HALFWAY HOUSE PROGRAM?
YES (If "YES," complete Item 13B)

Year

Day

Month

13B. DATE ENTERED PROGRAM
Month

Day

Year

NO

SECTION III: REMARKS

VA FORM
XXX 20XX

21-4193

SUPERSEDES VA FORM 21-4193, OCT 2022.

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VETERAN'S SOCIAL SECURITY NO.
REMARKS (Continued)

SECTION IV: SIGNATURE OF OFFICIAL
14. NAME AND TITLE OF INSTITUTIONAL OFFICIAL

15. DATE SIGNED
Month

16. SIGNATURE OF INSTITUTIONAL OFFICIAL (Required)

Date

Year

17. INSTITUTION TELEPHONE NUMBER
(Include Area Code)

Enter International Phone Number (If applicable)

PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of
1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research
studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and
delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation
Pension, Education, Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. Information submitted
is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The OMB control number for this project is 2900-0116, and it expires XX/XX/20XX. Public reporting burden for this collection of
information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at vapra@va.gov. Please refer to OMB Control No.
2900-0116 in any correspondence. Do not send your completed VA Form 21-4193 to this email address.

VA FORM 21-4193, XXX 20XX

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Where to Send Your Written Correspondence
Documents may be submitted by mail, in person at a VA regional office or electronically. However, VA
recommends submitting correspondence electronically as this is the fastest method of receipt.
VA provides several tools to assist in electronic submission. To learn more about how to submit documents
and claims electronically, visit www.va.gov/disability/upload-supporting-evidence. You can also go directly to
AccessVA to digitally upload any correspondence using QuickSubmit.
By visiting www.va.gov you can also check your claim status and learn about other VA benefits.
If you need assistance, you can find a local, accredited representative at https://www.benefits.va.gov/vso/.
If you prefer to mail your correspondence, please use the related mailing address below.
Compensation Benefits

Pension & Survivors Benefits

Department of Veterans Affairs
Compensation Intake Center
PO Box 4444
Janesville, WI 53547
Toll Free Phone: 1-800-827-1000
Toll Free Fax: (844) 531-7818

Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547
Toll Free Phone: 1-800-827-1000
Toll Free Fax: (844) 655-1604

Board of Veterans' Appeals

Fiduciary

Department of Veterans Affairs
Board of Veterans' Appeals
PO Box 27063
Washington, DC 20038
Toll Free Fax: (844) 678-8979

Department of Veterans Affairs
Fiduciary Intake Center
PO Box 5211
Janesville, WI 53547
Toll Free Phone: 1-800-827-1000
Toll Free Fax: (888) 581-6826

These addresses serve all United States
and foreign locations.
Veteran Crisis Line then Dial 988 then Press 1
You can also send a text message to 838255 to receive confidential support
24 hours a day, 7 days a week, 365 days a year.
For more information, visit
www.veteranscrisisline.net

VA FORM 21-4193, XXX 20XX

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