---
title: VA Form 21-4138 Online
description: Complete VA Form 21-4138 online to submit a statement in support of claim to the Department of Veterans Affairs.
seotitle: VA Form 21-4138 Online
seo-description: Complete VA Form 21-4138 online to submit a statement in support of claim to the Department of Veterans Affairs.
group: resources
indexable: true
llms: true
schema: webpage
published: 2026-03-29
updated: 2026-03-29
tags:
  - veterans benefits
  - disability
  - pension
  - supporting statement
path: /forms/va-21-4138
---
# VA Form 21-4138 Online

Complete VA Form 21-4138 online to submit a statement in support of claim to the Department of Veterans Affairs.

## How it works
1. **Fill out the form** - Complete the guided fields online.
2. **Add attachments** - Upload any required documents.
3. **Preview the PDF** - Review the final form before mailing.
4. **Mail it** - We print and mail the packet for you.


## Form summary
Use this online workflow when you need to add a written statement or clarification to a VA benefits claim. Complete the form, review the generated PDF, and continue to mailing.

## What you need
- Veteran or beneficiary identifying information
- Current mailing address
- A clear written statement supporting the claim
- Signature and date
- Signed form (wet signature required)
- Supporting evidence (optional) (optional) — Attach records or documents that support the statement, such as medical records, correspondence, or lay statements.

## Data collected
- Veteran or beneficiary identification details
- Mailing address and contact information
- Statement in support of claim
- Signature and signed date

## Where it gets mailed
Mailing destination:
- **Department of Veterans Affairs Evidence Intake Center**
- P.O. Box 4444
Janesville, WI 53547-4444

## Packet order
- Cover sheet (auto-generated)
- Completed form PDF
- Attachments (in the order you upload)

## Common mistakes
- Leaving the remarks section too vague to help the claim reviewer.
- Forgetting to sign and date page 2.
- Using an outdated mailing address for the VA Evidence Intake Center.
- Omitting claimant identification details that tie the statement to the VA file.

## Agent summary
This workflow collects claimant identification, contact information, remarks, and signature details needed to prepare VA Form 21-4138.

## For assistants
Use the Forms Draft API to prefill this form and generate a preview PDF.
- Endpoint: `POST /api/forms/va-21-4138/drafts`
- Payload: `{ fields: { ... }, attachments: [{ id, label, base64 }] }`
- Required fields: veteran_beneficiary_name, veteran_ssn, veteran_date_of_birth, mailing_address_line_1, mailing_city, mailing_state_province, mailing_zip_code, remarks_page_1, veteran_ssn_page_2, signature, date_signed
- Attachment IDs: supporting_evidence

## LLM field schema
```json
[
  {
    "id": "veteran_beneficiary_name",
    "label": "Veteran or beneficiary name",
    "type": "compound",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "claimant-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": [
      {
        "id": "first_name",
        "label": "First name",
        "metaClass": "name",
        "required": true,
        "uiWidth": "half",
        "pdfFieldName": "form1[0].#subform[0].Veterans_Beneficiary_First_Name[0]"
      },
      {
        "id": "middle_initial",
        "label": "Middle initial",
        "metaClass": "name",
        "required": false,
        "uiWidth": "quarter",
        "pdfFieldName": "form1[0].#subform[0].Middle_Initial1[0]"
      },
      {
        "id": "last_name",
        "label": "Last name",
        "metaClass": "name",
        "required": true,
        "uiWidth": "half",
        "pdfFieldName": "form1[0].#subform[0].Last_Name[0]"
      }
    ]
  },
  {
    "id": "veteran_ssn",
    "label": "Veteran social security number",
    "type": "compound",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "claimant-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": [
      {
        "id": "first_three",
        "label": "First 3 digits",
        "metaClass": "ssn",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "123",
        "pdfFieldName": "form1[0].#subform[0].SocialSecurityNumber_FirstThreeNumbers[0]"
      },
      {
        "id": "middle_two",
        "label": "Middle 2 digits",
        "metaClass": "ssn",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "45",
        "pdfFieldName": "form1[0].#subform[0].SocialSecurityNumber_SecondTwoNumbers[0]"
      },
      {
        "id": "last_four",
        "label": "Last 4 digits",
        "metaClass": "ssn_last4",
        "required": true,
        "uiWidth": "half",
        "placeholder": "6789",
        "pdfFieldName": "form1[0].#subform[0].SocialSecurityNumber_LastFourNumbers[0]"
      }
    ]
  },
  {
    "id": "va_file_number",
    "label": "VA file number (if applicable)",
    "type": "text",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "claimant-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "veteran_date_of_birth",
    "label": "Veteran date of birth",
    "type": "compound",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "claimant-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": [
      {
        "id": "month",
        "label": "Birth month",
        "metaClass": "date",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "MM",
        "pdfFieldName": "form1[0].#subform[0].Veterans_DOB_Month[0]"
      },
      {
        "id": "day",
        "label": "Birth day",
        "metaClass": "date",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "DD",
        "pdfFieldName": "form1[0].#subform[0].DOB_Day[0]"
      },
      {
        "id": "year",
        "label": "Birth year",
        "metaClass": "date",
        "required": true,
        "uiWidth": "half",
        "placeholder": "YYYY",
        "pdfFieldName": "form1[0].#subform[0].DOB_Year[0]"
      }
    ]
  },
  {
    "id": "service_number",
    "label": "Veteran service number (if applicable)",
    "type": "text",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "claimant-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "telephone_number",
    "label": "Telephone number (U.S.)",
    "type": "compound",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": [
      {
        "id": "area_code",
        "label": "Area code",
        "metaClass": "phone",
        "required": false,
        "uiWidth": "quarter",
        "placeholder": "414",
        "pdfFieldName": "form1[0].#subform[0].TelephoneNumber_FirstThreeNumbers[0]"
      },
      {
        "id": "prefix",
        "label": "Prefix",
        "metaClass": "phone",
        "required": false,
        "uiWidth": "quarter",
        "placeholder": "555",
        "pdfFieldName": "form1[0].#subform[0].TelephoneNumber_SecondThreeNumbers[0]"
      },
      {
        "id": "line_number",
        "label": "Line number",
        "metaClass": "phone",
        "required": false,
        "uiWidth": "half",
        "placeholder": "0123",
        "pdfFieldName": "form1[0].#subform[0].TelephoneNumber_LastFourNumbers[0]"
      }
    ]
  },
  {
    "id": "international_phone_number",
    "label": "International phone number (if applicable)",
    "type": "text",
    "required": false,
    "meta_class": "phone",
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "email_address",
    "label": "Email address",
    "type": "text",
    "required": false,
    "meta_class": "email",
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "mailing_address_line_1",
    "label": "Mailing address line 1",
    "type": "text",
    "required": true,
    "meta_class": "address",
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "mailing_address_line_2",
    "label": "Apartment or unit number",
    "type": "text",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "mailing_city",
    "label": "City",
    "type": "text",
    "required": true,
    "meta_class": "city",
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "mailing_state_province",
    "label": "State or province",
    "type": "text",
    "required": true,
    "meta_class": "state",
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "mailing_zip_code",
    "label": "ZIP or postal code",
    "type": "compound",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": [
      {
        "id": "first_five",
        "label": "First 5 digits",
        "metaClass": "zip",
        "required": true,
        "uiWidth": "half",
        "placeholder": "53202",
        "pdfFieldName": "form1[0].#subform[0].MailingAddress_ZIPOrPostalCode_FirstFiveNumbers[0]"
      },
      {
        "id": "last_four",
        "label": "Last 4 digits",
        "metaClass": "zip",
        "required": false,
        "uiWidth": "half",
        "placeholder": "1041",
        "pdfFieldName": "form1[0].#subform[0].MailingAddress_ZIPOrPostalCode_LastFourNumbers[0]"
      }
    ]
  },
  {
    "id": "mailing_country",
    "label": "Country",
    "type": "text",
    "required": false,
    "meta_class": "country",
    "ui_width": null,
    "group_id": "contact-information",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "remarks_page_1",
    "label": "Statement in support of claim",
    "type": "textarea",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "remarks",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "remarks_page_2",
    "label": "Statement continuation (page 2)",
    "type": "textarea",
    "required": false,
    "meta_class": null,
    "ui_width": null,
    "group_id": "remarks-continuation",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "veteran_ssn_page_2",
    "label": "Veteran social security number for page 2 header",
    "type": "compound",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "declaration",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": [
      {
        "id": "first_three",
        "label": "First 3 digits",
        "metaClass": "ssn",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "123",
        "pdfFieldName": "form1[0].#subform[1].SocialSecurityNumber_FirstThreeNumbers[1]"
      },
      {
        "id": "middle_two",
        "label": "Middle 2 digits",
        "metaClass": "ssn",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "45",
        "pdfFieldName": "form1[0].#subform[1].SocialSecurityNumber_SecondTwoNumbers[1]"
      },
      {
        "id": "last_four",
        "label": "Last 4 digits",
        "metaClass": "ssn_last4",
        "required": true,
        "uiWidth": "half",
        "placeholder": "6789",
        "pdfFieldName": "form1[0].#subform[1].SocialSecurityNumber_LastFourNumbers[1]"
      }
    ]
  },
  {
    "id": "signature",
    "label": "Signature of veteran or beneficiary",
    "type": "signature",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "declaration",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": null
  },
  {
    "id": "date_signed",
    "label": "Date signed",
    "type": "compound",
    "required": true,
    "meta_class": null,
    "ui_width": null,
    "group_id": "declaration",
    "choice_group": null,
    "choice_label": null,
    "visibility": null,
    "compound_subfields": [
      {
        "id": "month",
        "label": "Signed month",
        "metaClass": "date",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "MM",
        "pdfFieldName": "form1[0].#subform[1].Date_Signed_Month[0]"
      },
      {
        "id": "day",
        "label": "Signed day",
        "metaClass": "date",
        "required": true,
        "uiWidth": "quarter",
        "placeholder": "DD",
        "pdfFieldName": "form1[0].#subform[1].Date_Signed_Day[0]"
      },
      {
        "id": "year",
        "label": "Signed year",
        "metaClass": "date",
        "required": true,
        "uiWidth": "half",
        "placeholder": "YYYY",
        "pdfFieldName": "form1[0].#subform[1].Date_Signed_Year[0]"
      }
    ]
  }
]
```

## Sources
- [About VA Form 21-4138](https://www.va.gov/forms/21-4138/)
- [Official instructions](https://www.va.gov/forms/21-4138/)

## Last verified
2026-03-27


## FAQs
- **When should I use VA Form 21-4138?** Use VA Form 21-4138 when you need to submit a written statement, clarification, or explanation in support of a VA benefits claim.
- **Do I need to sign VA Form 21-4138?** Yes. The form requires the veteran or beneficiary to sign and date the declaration section on page 2.
- **Can I attach supporting evidence with this form?** Yes. If your statement refers to medical records, correspondence, buddy statements, or other evidence, include those attachments with your mailing.


## Related
- [VA Form 21-4138 vs 21-10210](/veterans/va-form-21-4138-vs-21-10210)
- [Fill out official PDF forms online](/fill-out-official-pdf-forms-online)