AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION

PART I - PERSONAL INFORMATION
VETERAN'S NAME (First, middle initial, last)

VETERAN'S FILE NUMBER

VETERAN'S DATE OF BIRTH

IF I AM NOT THE VETERAN, MY NAME IS (First, middle initial, last)

MY DATE OF BIRTH (If I am not the Veteran)

I AM EXPERIENCING HOMELESSNESS

MY PREFERRED MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

MY PREFERRED TELEPHONE NUMBER (Include Area Code)

MY PREFERRED E-MAIL ADDRESS

MY REPRESENTATIVE'S NAME

PART II - BOARD REVIEW OPTION (Check only one)
10. A Veterans Law Judge will consider your appeal in the order in which it is received, depending on which of the following review options you select.
(For additional explanation of your options, please see the attached information and instructions.)
Direct Review by a Veterans Law Judge: I do not want a Board hearing, and will not submit any additional evidence in support of my appeal. (Choosing this option often results in the Board issuing its decision most quickly.)
Evidence Submission Reviewed by a Veterans Law Judge: I have additional evidence in support of my appeal that I will submit to the Board with my VA Form 10182 or within the 90 days of the Board's receipt of my VA Form 10182. (Choosing this option will extend the time it takes for the Board to decide your appeal.)

• Hearing with a Veterans Law Judge: I want a Board hearing and the opportunity to submit additional evidence in support of my appeal that I will provide within 90 days after my hearing. I want the hearing type below: (Choosing this option will extend the time it takes for the Board to decide your appeal.)

  • Central Office Hearing (I will attend in person in Washington, DC)

  • Videoconference Hearing (I will go to a Regional Office)

  • Virtual Telehearing (I will attend using an internet-connected device) (Important: Provide your e-mail address and Representative in Part I)

PART III - SPECIFIC ISSUE(S) TO BE APPEALED TO A VETERANS LAW JUDGE AT THE BOARD
Please list each issue decided by VA that you would like to appeal. Please refer to your decision notice(s) for a list of adjudicated issues. For each issue, please identify the date of VA's decision and the area of disagreement (e.g., service connection, disability evaluation, or effective date of award).
check
Check

Check here if you attached additional sheets. Include the Veteran's last name and the file number

PART IV - CERTIFICATION AND SIGNATURE
Signature
Clear

Date Signed