February 25, 2005 M21-1, Part III
Request for Lay Evidence
(For Use in Development for Lay Evidence in PGW Claim—Initial Request)
The above veteran currently has a claim for Department of Veterans Affairs (VA) disability benefits pending in this office. He has reported that you may have personal knowledge which may help support his (her) claim.
What We Need
In order to assist the veteran with his (her) claim, we are asking that you furnish the following information:
A. Please describe exactly what you observed, giving dates and places. (Be sure to include specific month,
day and year.) If you are in an occupation which would qualify you as an expert witness, e.g., medical doctor, nurse, etc., please include this information. Your statement should describe factual events or conditions which you witnessed or know with reasonable certainty occurred.
B. Include information based on your personal knowledge and your observations of the level of severity and the duration.
C. Please provide information concerning your relationship to the veteran which enabled you to make your observations.
D. If you were on active duty at the time, please include your former rank, organization and service serial number.
What You Should Do Next
We are enclosing VA Form 21-4138 for your convenience in replying. This form includes the statement that you are certifying the information to be true to the best of your knowledge and belief. If you choose not to use this form, please include this certification on whatever document is submitted.
When We Need The Requested Information
This evidence should be furnished as soon as possible, preferably within 60 days. The sooner we receive what we need, the sooner we’ll be able to determine the veteran’s entitlement to benefits.
It may expedite the veteran’s claim is you would fax the report to us. Our fax number is (XXX) XXX-XXXX. If you do fax this evidence, please clearly write the veteran’s name and VA claim number on each page. The veteran’s VA claim number is located at the top of this letter above the veteran’s name.