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

Fill out VA Form 21-0781 online by answering plain-English questions. Claim Raven puts your answers on the official March 2024 edition of the form, and you download the filled PDF ready to sign. It is free with a Claim Raven account.

What VA Form 21-0781 is for

An optional statement you file with a claim for a mental health condition, such as PTSD, depression or anxiety, that you connect to a traumatic event in service. It is not the claim itself: a new claim still needs Form 21-526EZ, and a claim after a prior decision needs Form 20-0995. If writing about the event is hard right now, the Veterans Crisis Line is printed on the form itself: call 988 and press 1, text 838255 or chat at VeteransCrisisLine.net.

Want to tell what happened and how it affects you in your own words? The personal statement builder writes a separate statement. It does not fill in Form 21-0781. Write my own statement free.

Parts someone else completes

Sections VIII to X on page 7 apply only when you sign with an "X" (two witnesses sign), when an alternate signer signs for you, or when a representative with power of attorney signs. Those people complete and sign their own sections.

What you fill in by hand

The filler never asks for your Social Security number, VA file number, date of birth or signature. You write those in by hand. Leave these boxes for yourself:

  • Item 2: Social Security number
  • Item 3: VA file number
  • Item 4: date of birth
  • Item 5: service number
  • Item 6: international phone number
  • Items 16A and 16B: signature and date signed
  • Sections VIII to X on page 7

Where to send it

  • Send it with your claim: Form 21-526EZ for a new claim, or Form 20-0995 after a prior decision.
  • Applying online: VA's form page says to upload the PDF and select the option showing you already completed Form 21-0781, so you can skip the online PTSD questions.
  • By mail: Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
  • If you want VA to request private provider or Vet Center records, also send Forms 21-4142 and 21-4142a.
  • Keep a copy and your submission receipt.

Claim Raven does not submit forms to VA. You review the filled PDF, sign and date it, and send it to VA yourself. Claim Raven is independent and is not affiliated with VA.

Official form and guide

This filler uses the March 2024 edition of the form.