February 25, 2005M21-1, Part III
Follow-up Request for Lay Evidence
(For Use if Additional Information Is Needed to Clarify Response to Initial Request)
The above veteran currently has a claim for Department of Veterans Affairs (VA) disability benefits pending in this office. Thank you for providing us with your [Insert date] lay statement; however, we need the following additional information.
What We Need
In order to assist the veteran with is claim, we are asking that you furnish the following additional information:
[The following are 5 optional paragraphs. Select the paragraph or paragraphs needed.}
(1) List all symptoms/conditions that you have observed.
(2) The specific month, day and year that you first noticed each condition/symptom.
(3) Length of time each condition/symptom was observed.
(4) Frequency of each condition/symptom observed (i.e., 1, 2, 3 times a day, week, month, etc.)
(5) Result or impact of each condition/symptom observed on the veteran (i.e., did he (she) take medicines or seek medical help, and if so, how often; did he(she) miss work or school, and if so, how often; did it affect relationships with family and friends, and if so, describe in detail).
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 if you would fax the report to us. Our fax number is (XXX) XXX-XXXX. If you do fax the 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.