U.S. Department of Veterans Affairs

Fill out VA Form 21-10210 online

Lay/Witness Statement

VA Form 21-10210 is a written statement that supports a VA claim. A veteran or other claimant can use it to give their own statement, and another person can use it to describe what they know or have seen about the facts of the claim. VA notes that people also call it a "buddy statement."

Fill out VA Form 21-10210 Blank form from the VA

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Edition: JUL 2024
Pages: 3
Fillable fields: 76
Checked against the VA: November 8, 2026

GuruPDF is not affiliated with the U.S. Department of Veterans Affairs. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses VA Form 21-10210

Veterans who want to add their own written statement to a VA claim
Claimants who are not the veteran, such as an eligible family member with their own claim
People who served with the veteran or claimant
Family members and friends of the veteran or claimant
Coworkers or supervisors of the veteran or claimant

Before you start

The veteran's name, Social Security number, date of birth and VA file number, if there is one
The VA insurance file number, if there is one
If the claimant is not the veteran: the claimant's name, Social Security number, date of birth, address and contact details
The claimed issue the statement is about
Notes on what the person writing the statement knows or has seen first-hand about the facts of the claim
If a witness is writing it: the witness's name, telephone number, email address and relationship to the veteran or claimant

How to fill out VA Form 21-10210

Section I, items 1-8: veteran's identification
Enter the veteran's name, Social Security number, VA file number (if applicable), date of birth and VA insurance file number (if applicable). Add the current mailing address (if applicable), a telephone number (there is a separate box for an international number) and an email address. Next to the email box you can tick that you agree to receive electronic correspondence from VA about the claim.
Section II, items 9-16: claimant's identification
Fill in this section only if the claimant is not the veteran. It asks for the same details about the claimant: name, Social Security number, VA file number, date of birth, VA insurance file number, mailing address, telephone number and email address, with the same box for electronic correspondence.
Section III, item 17: the statement
The statement box starts on page 2 and continues on page 3. Say which claimed issue the statement addresses. Then describe what the writer personally knows or has observed about the facts or circumstances that matter to the claim. The Social Security number box at the top of pages 2 and 3 is for the same number as item 2 on page 1.
Section IV, items 18-21: witness contact information
Fill in this section if the statement in Section III comes from someone else writing on the veteran's or claimant's behalf. Enter the witness's name, tick every relationship that applies in item 19 (served with, family or friend, coworker or supervisor, or other, with a short description), and give the witness's telephone number and email address.
Section V, items 22A-22B: certification and signature
The person who made the statement certifies that they completed it and that its information is true and correct to the best of their knowledge and belief. They sign in item 22A, which the form marks as required, and enter the date signed in 22B.

After you fill it out

The completed statement goes to VA. The form's instructions say to send it with your application when you, or someone writing on your behalf, give a statement to support your claim. Page 1 prints the mailing address for VA's Evidence Intake Center; use the address printed on the current form from VA's form page. VA also lets you submit the same statement online on VA.gov instead of mailing the paper form.

Signing: Item 22A is the signature of the veteran, claimant or witness who made the statement, and the form marks it as required; item 22B is the date signed. The form does not say whether the signature must be handwritten, so follow VA's instructions for the way you send it.

Watch out for

The form warns that the law provides severe penalties, which include a fine, imprisonment or both, for willfully submitting any statement or evidence of a material fact that you know is false.
Use one form for each statement. The form says that an additional statement of your own, or a statement from each additional witness, needs a separate VA Form 21-10210.
Do not send the completed form to the email address in the Respondent Burden notice on page 3. The form says that address is only for comments on the burden estimate.

Questions about VA Form 21-10210

What is a buddy statement?

VA says people sometimes call the lay/witness statement on VA Form 21-10210 a "buddy statement." It is written testimony from you or from someone who knows about your condition or the events related to your claim.

Who can write a lay statement?

VA says anyone can provide lay evidence, and the person does not need any specific training or education. On this form the witness's relationship can be someone who served with the veteran or claimant, a family member or friend, a coworker or supervisor, or another relationship you describe.

Can several people write on one form?

No. VA asks for a separate form for each statement. If more than one person writes a statement to support a claim, each person uses their own form.

Do I have to use this form for a lay statement?

For disability claims, VA's evidence page lists three ways to give lay evidence: a statement written on a blank piece of paper, VA Form 21-10210, or a Statement in Support of Claim (VA Form 21-4138). VA reviews lay evidence along with the other evidence in the claim.

Can I write a statement for someone else's claim?

Yes. VA says you can submit a statement to support your own claim or someone else's. To support someone else's claim, you need details such as their date of birth, Social Security number, VA file number (if available) and contact information.