VA Form 21-0833 Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1. NAME OF VETERAN (First, Middle, Last)FirstMiddleLast2. VETERAN'S SOCIAL SECURITY NUMBER3. VA FILE NUMBER4. VETERAN'S ADDRESS (Number, street or rural route, City or P.O., State and ZIP Code)5. TELEPHONE NUMBER(S) A. DAYTIME (Include Area Code)B. EVENINGB. EVENING (Include Area Code)6. E-MAIL ADDRESS (If applicable)7. I WOULD LIKE TO FILE A CLAIM FOR: (Check all that apply)INCREASED EVALUATION OF THE DISABILITY(IES) FOR WHICH I AM ALREADY SERVICE CONNECTED (Provide the name of the disability(ies))SERVICE CONNECTION FOR NEW DISABILITY(IES) (List your new disability(ies))REOPENING OF PREVIOUSLY DENIED DISABILITY(IES) (List your previously denied disability(ies))DISABILITY(IES) SECONDARY TO MY EXISTING SERVICE CONNECTED DISABILITY(IES) (Provide the name of the disability(ies) and your service connected condition(s))8A. NAME AND LOCATION OF VA MEDICAL CENTER THAT HAS MY RELEVANT TREATMENT RECORDS 8B. NAME AND ADDRESS OF MILITARY FACILITY THAT HAS MY RELEVANT TREATMENT RECORDS8C. DO YOU HAVE PRIVATE TREATMENT RECORDS?YESNO(If "Yes," please attach the treatment records to this form. If you would like to have VA request your private treatment records, please attach a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, for each private treatment provider. The form is available at www.va.gov/vaforms.)9. I WOULD LIKE TO FILE A CLAIM FOR OTHER VA BENEFITS (Check appropriate box)AID AND ATTENDANCEAUTOMOBILE ALLOWANCEOTHER (Specify benefit)OTHER (Specify benefit)10. I WOULD LIKE TO FILE A CLAIM FOR ADDITIONAL BENEFITS BECAUSE MY SPOUSE IS SERIOUSLY DISABLED (Please provide spouse's name and social security number in Items 10A & 10B)A. SPOUSE'S NAMEB. SPOUSE'S SOCIAL SECURITY NOSubmit
