VA Form 21-0781 — Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s)

What is VA Form 21-0781?

VA Form 21-0781 is a statement you give the U.S. Department of Veterans Affairs (VA) in support of a claimed mental health disorder, such as post-traumatic stress disorder (PTSD), depression, anxiety or bipolar disorder, that you connect to a traumatic event during service. The form covers combat events, personal traumatic events including military sexual trauma (MST), and other traumatic events such as accidents or witnessing a death.

The form is optional, but VA says completing it could help your claim: VA can use what you provide to search your military records and other sources for evidence. It does not replace the claim itself. You still file VA Form 21-526EZ for a new or increased claim, or VA Form 20-0995 for a Supplemental Claim. If you apply online at VA.gov, the application asks these mental health questions itself.

FileIt asks the form's questions one section at a time and prints your answers on VA's own PDF, with names in the letter-per-box rows and longer answers wrapped to fit their boxes. Questions that only apply in some cases, such as the report details or the MST notification choice, appear only when they do. The finished statement is saved to your vault, where you can send it for e-signature or print and sign it.

Who needs to fill out VA Form 21-0781?

• Veterans and service members claiming disability compensation for PTSD or another mental health condition caused by an in-service traumatic event.
• Claimants who filed a paper claim, or an online claim without answering the mental health questions, and want to describe the events.
• Anyone who received a VA letter asking for a statement about an in-service traumatic event.

When to use VA Form 21-0781

• With, or after, your VA Form 21-526EZ claim for a mental health condition.
• With a Supplemental Claim (VA Form 20-0995) when you have new and relevant evidence about the events.
• When VA writes to ask for more information about the traumatic event behind your claim.

What you need before you start

• Your identification details: name, Social Security number, VA file number and service number if you have them, date of birth, phone and email.
• For each traumatic event, a brief description, the location (for example the unit, base or duty station) and the date or approximate date.
• Any behavioral changes you noticed afterwards, such as more or fewer visits to health care providers, use of leave, changes in performance, or alcohol use, and any record of them.
• Whether an official report was filed, and its type (restricted or unrestricted, police or other report).
• Possible sources of evidence, such as counseling centers, family members, fellow service members or diaries.
• Where you were treated (VA medical centers, Vet Centers, community care, military or private providers) and approximate dates.

What’s on VA Form 21-0781

The 2024 edition has 7 pages. FileIt asks for it in 12 parts, and it is signed by Veteran:

1. Section I: Veteran/service member's identification informationVeteran
2. Section II: Traumatic event(s) informationVeteran
3. Section II (continued): Traumatic events 4 to 6Veteran
4. Section III: Additional information - 10. Behavioral changesVeteran
5. Section III (continued): Reports and sources of evidenceVeteran
6. Section IV: Treatment informationVeteran
7. Section V: RemarksVeteran
8. Section VI: VBA notifying VHA about upcoming eventsVeteran
9. Section VII: Certification and signatureVeteran
10. Section VIII: Witnesses to signatureVeteran
11. Section IX: Alternate signerVeteran
12. Section X: Power of attorney (POA) signatureVeteran

How to fill out VA Form 21-0781, step by step

1 Section I: Identification

Your name, Social Security number, VA file number, date of birth, service number, phone and email.

2 Section II: Traumatic event(s)

Tick the type of each event (combat, personal not involving MST, personal involving MST, or other), then describe up to six events with their location and dates. Approximate dates and places are acceptable, and giving other people's names is not required. Use Section V for more.

3 Section III: Additional information

For personal traumatic events, tick any behavioral changes that followed and add details. Then say whether an official report was filed and list possible sources of evidence. If your events were combat only, the form says you may skip to item 11.

4 Section IV: Treatment

Say whether you have been treated for the impact of the events, where, and roughly when. If VA medical center, CBOC or military treatment began in 2005 or later, you don't need to give dates. For private or Vet Center records, VA asks for VA Forms 21-4142 and 21-4142a.

5 Sections V and VI: Remarks and VHA notification

Add anything else that supports your claim. If you ticked MST, you can choose whether VBA may notify VHA about upcoming events in your claim, such as examinations. Your choice doesn't affect the outcome, and you can change it.

6 Sections VII to X: Signature

Sign and date item 16A. If you sign with an X, two witnesses sign too. An alternate signer or POA signs only if 16A is blank, and only with a valid VA Form 21-0972 or 21-22 / 21-22a on record.

Common mistakes to avoid

• Sending the statement on its own instead of with, or after, the claim it supports (VA Form 21-526EZ or 20-0995).
• Leaving out the location and approximate dates of each event. Approximate details still help VA search the records.
• Ticking 'None' in item 12 together with a source of evidence.
• Forgetting VA Forms 21-4142 and 21-4142a when you want VA to request private or Vet Center records.
• Leaving the signature in 16A blank without a valid alternate signer or POA form on record.

After you fill it out

Sign it (FileIt can send it for e-signature) and submit it: upload it at VA.gov or mail it to the Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444. FileIt does not submit it for you.

A lay or witness statement can be added on VA Form 21-10210, and VA may ask fellow veterans for their DD Form 214.

Keep FileIt's copy in your vault with your claim. If you need support, the form gives the Veterans Crisis Line: call 988 and press 1, text 838255, or chat at veteranscrisisline.net.

VA Form 21-0781: frequently asked questions

Official sources

• Blank form (PDF), published by U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA): https://www.vba.va.gov/pubs/forms/VBA-21-0781-ARE.pdf
• Official instructions and guidance: https://www.va.gov/find-forms/about-form-21-0781/
• Edition shown on this page: VA Form 21-0781, MAR 2024 (OMB No. 2900-0659, expires 03/31/2027) (checked 2026-10-25).

FileIt is not affiliated with or endorsed by U.S. Department of Veterans Affairs, Veterans Benefits Administration (VBA) or any government. This page explains the form in general terms and is not legal, tax or immigration advice. Always read the official instructions, and check that you are using the edition the recipient accepts. Page last reviewed 2026-10-25.

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