Appointment Lines:
POP - 1.809.690.2738
Fax Number:
(321) 320-8776

INFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY

    SECTION I - VETERAN'S IDENTIFICATION INFORMATION






    SECTION II - BENEFICIARY/CLAIMANT'S IDENTIFICATION INFORMATION












    SECTION III - CONTACT INFORMATION




















    F[0].#subform[2].LIMITED_INFORMATION[0]
    F[0].#subform[2].ANY_INFORMATION[0]


    F[0].#subform[2].Status_Of_Pending_Claim_Or_Appeal[0]
    F[0].#subform[2].CURRENT_BENEFIT_AND_RATE[0]
    F[0].#subform[2].AMOUNT_OF_MONEY_OWED_VA[0]
    F[0].#subform[2].REQUEST_A_BENEFIT_PAYMENT_LETTER[0]
    F[0].#subform[2].PAYMENT_HISTORY[0]
    F[0].#subform[2].CHANGE_OF_ADDRESS_OR_DIRECT_DEPOSIT[0]



    F[0].#subform[2].One_time_only[0]
    F[0].#subform[2].FROM_THE_DATE_OF_SIGNING_BELOW_UNTIL[0]

    F[0].#subform[2].ONGOING_UNTIL_WRITTEN_NOTICE_IS_GIVEN_TO_VA_TO_TERMINATE[0]


    F[0].Page_2[0].CheckBox1[0]


    F[0].#subform[2].THE_CITY_AND_STATE_YOUR_MOTHER_WAS_BORN_IN[0]


    F[0].#subform[2].THE_NAME_OF_THE_HIGH_SCHOOL_YOU_ATTENDED[0]


    F[0].#subform[2].YOUR_FIRST_PETS_NAME[0]


    F[0].#subform[2].YOUR_FAVORITE_TEACHERS_NAME[0]


    F[0].#subform[2].YOUR_FATHERS_MIDDLE_NAME[0]

    SECTION IV - DECLARATION OF INTENT

    HELP US CONTINUE OUR MISSION

    Your gift will ensure veterans and their families can access the full range of benefits they deserve, provide care and support during tough times.VAFMSF fights for Veterans outside the United States and will Continue to Move forward with care for Veterans and Family Members.