Edit VA Form 21-0781 online free, or download the PDF
VA PTSD and Mental Health Statement: Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s)
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VA Form 21-0781 in short
VA Form 21-0781 is an optional statement about a mental health condition, such as PTSD, depression, or anxiety, linked to a traumatic event during military service. VA uses the details to look for records and other evidence that support a disability claim. It covers combat events, military sexual trauma (MST), other personal traumatic events, and other traumatic events. It does not replace the claim form itself.
| Issued by | U.S. Department of Veterans Affairs (VA), Veterans Benefits Administration |
|---|---|
| Current version | Rev. March 2024 (checked 2026-10-25) |
| Who fills it in | Veterans and service members claiming a mental health condition due to an in-service traumatic event. VA's form page says you may want to send it if you filed online and skipped the mental health questions, filed with a paper 21-526EZ, or got a VA letter asking for it. |
| Who receives it | VA, at the Evidence Intake Center in Janesville, Wisconsin. |
| Where to send it | By mail, the form says to send it to: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. VA's form page says that if you answer the optional mental health questions in the online VA Form 21-526EZ, you do not need to send this form separately. |
| Deadline | The form has no deadline of its own. It supports a claim filed on VA Form 21-526EZ or VA Form 20-0995. Follow any date in a VA letter. |
| Official links | Official page · Official PDF |
What changed
The MAR 2024 edition supersedes the JUN 2021 edition, as printed on the form. VA did not publish a list of changes.
How to fill out VA Form 21-0781, line by line
| Section I, items 1 to 7 | Identification Veteran or service member's name, SSN, VA file number, date of birth, service number, phone, and email (optional). |
| Section II, item 8 | Type of traumatic event Check all that apply: combat, personal traumatic events involving MST, personal traumatic events not involving MST, and other traumatic events. |
| Section II, items 9A to 9C | Event details A brief description, location, and dates of each event. Approximate dates are acceptable. The form gives examples. VA says it will not contact people you name. |
| Section III, item 10 | Behavioral changes For personal traumatic events, check behavioral changes that followed, such as changes in performance, use of leave, or substance use, and add details. Combat-only claims can skip to item 11. |
| Section III, items 11 and 12 | Reports and evidence sources Whether an official report was filed (restricted, unrestricted, police, or other) and possible sources of evidence, such as family, clergy, counseling centers, or diaries. |
| Section IV, item 13 | Treatment Whether and where you received treatment, with facility names and approximate dates. For private providers or Vet Centers, VA needs VA Forms 21-4142 and 21-4142a. |
| Section V, item 14 | Remarks Optional extra space for any answer. |
| Section VI, item 15 | VHA notification option Only for MST claims. Choose whether VBA may notify VHA about upcoming exams, hearings, and decisions. |
| Sections VII and VIII, items 16 to 18 | Signature and witnesses The veteran or service member signs and dates. Two witnesses sign only if the signature is made with an X. |
| Items 19 and 20 | Alternate signer or representative For an alternate signer or a power of attorney or authorized representative signing on the claimant's behalf. |
Common mistakes to avoid
- Sending this form instead of a claim. The form says you must also submit VA Form 21-526EZ for a new or increased claim, or VA Form 20-0995 for a Supplemental Claim.
- Sending it again after answering the mental health questions in the online 21-526EZ. VA says you do not need to.
- Expecting VA to get private treatment records without consent. The form says VA needs VA Forms 21-4142 and 21-4142a for private providers or Vet Centers.
- Leaving item 9 blank because you cannot remember exact dates. The form says approximate dates are acceptable.
- Putting witness statements on this form. The form points to VA Form 21-10210 for statements from people who know about the event or the behavior changes.
- Signing with an X without two witnesses in Section VIII.
Questions about VA Form 21-0781
Is VA Form 21-0781 required for a PTSD claim?
No. Both the form and VA's form page say it is optional, but it could help VA find evidence for your claim.
Do I need this form if I file my claim online?
VA's form page says that if you answer the optional mental health questions in the online 21-526EZ, you do not need to submit VA Form 21-0781 separately.
Will VA contact the people I name in the statement?
The form says that if you name other people who were involved or present, VA will not contact them.
Where do I mail VA Form 21-0781?
The form gives Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Who can I call with questions?
The form lists 1-800-698-2411 (TTY: 711) and Ask VA at ask.va.gov. If you are in crisis, it lists the Veterans Crisis Line: dial 988 and press 1, or text 838255.
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Sources
Checked against the official sources on 2026-10-25. PDF Editor Hub is not affiliated with the U.S. Department of Veterans Affairs or any government agency. This page is general information, not legal or tax advice.