OMB Approved No.

2900-0659
Respondent Burden: 1 hour 10 minutes
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION

FOR POST-TRAUMATIC STRESS DISORDER (PTSD)
INSTRUCTIONS: List the stressful incident or incidents that occurred in service that you feel contributed to your current
condition. For each incident, provide a description of what happened, the date, the geographic location, your unit assignment and
dates of assignment, and the full names and unit assignments of you know of who were killed or injured during the incident. Please
provide dates within at least a 60-day range and do not use nicknames. It is important that you complete the form in detail and be as
specific as possible so that research of military records can be thoroughly conducted. If more space is needed, attach a separate
sheet, indicating the item number to which the answers apply.
1. NAME OF VETERAN (First, Middle, Last) 2. VA FILE NO.

STRESSFUL INCIDENT NO. 1

3A. DATE INCIDENT OCCURRED (Mo., day, yr.) 3B. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

3C. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, 3D. DATES OF UNIT ASSIGNMENT (Mo., day, yr.)
CAVALRY, SHIP)
FROM TO

3E. DESCRIPTION OF THE INCIDENT

3F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT

INFORMATION ABOUT SERVICEPERSONS WHO WERE KILLED OR INJURED DURING INCIDENT NO. 1
(ATTACH A SEPARATE SHEET IF MORE SPACE IS NEEDED)
4A. NAME OF SERVICEPERSON (First, Middle, Last) 4B. RANK 4C. DATE OF INJURY/DEATH (Mo., day, yr.)

4D. PLEASE CHECK ONE 4E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,
CAVALRY, SHIP)
KILLED IN ACTION WOUNDED IN ACTION

KILLED NON-BATTLE INJURED NON-BATTLE

5A. NAME OF SERVICEPERSON (First, Middle, Last) 5B. RANK 5C. DATE OF INJURY/DEATH (Mo., day, yr.)

5D. PLEASE CHECK ONE 5E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION,
KILLED IN ACTION WOUNDED IN ACTION CAVALRY, SHIP)

KILLED NON-BATTLE INJURED NON-BATTLE

VA FORM PAGE 1
JAN 2014
21-0781 SUPERSEDES VA FORM 21-0781, OCT 2007,
WHICH WILL NOT BE USED.
 STRESSFUL INCIDENT NO. 2
6A. DATE INCIDENT OCCURRED (Mo.,day, yr.) 6B. LOCATION OF INCIDENT (City, State, Country, Province, landmark or military installation)

6C. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING, BATTALION, 6D. DATES OF UNIT ASSIGNMENT (Mo.,day,yr.)
CAVALRY, SHIP) FROM TO

6E. DESCRIPTION OF THE INCIDENT

6F. MEDALS OR CITATIONS YOU RECEIVED BECAUSE OF THE INCIDENT

INFORMATION ABOUT SERVICEPERSONS WHO WERE KILLED OR INJURED DURING INCIDENT NO. 2
(ATTACH A SEPARATE SHEET IF MORE SPACE IS NEEDED)
7A. NAME OF SERVICEPERSON (First, Middle, Last) 7B. RANK 7C. DATE OF INJURY/DEATH (Mo. day, yr.)

7D. PLEASE CHECK ONE 7E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING,
KILLED IN ACTION WOUNDED IN ACTION
BATTALION, CAVALRY, SHIP)

KILLED NON-BATTLE INJURED NON-BATTLE

8A. NAME OF SERVICEPERSON (First, Middle, Last) 8B. RANK 8C. DATE OF INJURY/DEATH (Mo. day, yr.)

8D. PLEASE CHECK ONE 8E. UNIT ASSIGNMENT DURING INCIDENT (Such as, DIVISION, WING,
BATTALION, CAVALRY, SHIP)
KILLED IN ACTION WOUNDED IN ACTION
KILLED NON-BATTLE INJURED NON-BATTLE

9. REMARKS

I certify that the foregoing statement(s) are true and correct to the best of my knowledge and belief.
10. SIGNATURE 11. DATE 12. TELEPHONE NUMBERS (Include Area Code)
DAYTIME EVENING

PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material
fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under
the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional
communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a
party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and
Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. However, the requested information is
necessary to obtain supporting evidence of stressful incidents in service. If the information is not furnished completely or accurately, VA will not
be able to thoroughly research your military records for supporting evidence. The responses you submit are considered confidential (38 U.S.C.
5701).
RESPONDENT BURDEN: We need this information in order to assist you in supporting your claim for post-traumatic stress disorder (38 U.S.
C. 5107 (a)). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour 10 minutes
to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid
OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB
control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to
get information on where to send comments or suggestions about this form.
VA FORM 21-0781, JAN 2014 PAGE 2