How to fill out a VA Form 21-4138
by Joe Sipala
This step-by-step guide will help you to fill out a STATEMENT IN SUPPORT OF CLAIM on VA Form 21-4138. (The link will take you to a page where you can type all your information, save it to a disk and print a clean copy.)
1. Type your FIRST NAME - MIDDLE NAME - LAST NAME in the box provided.
2. For the form you will send the VA, type your full SSN and your C/CSS (if you have one).
For Statements you are sending to Joe Sipala, type your SSN 000-444-1234 (Last four) and your C-Number 00-000-123 (Last three).
3. When you write your statement, write it like you're talking to a judge or an attorney who's trying to discredit you. That's exactly who you're really writing to and that’s exactly what they’re trying to do - discredit you and prove you’re lying.
Be specific. Be to the point. State only what you know by what you saw or did. Do not make any statement that, if asked if you can verify it, you must truthfully answer, "No".
Consider using the following format:
I served in the (branch of military) from (date) to (date) and was honorably discharged. (Note: anything less than honorably and the VA will look down on you - but don’t let that stop you filing a claim).
I was stationed at (name of base), Okinawa, from (date) to (date). My job included (MOS description). Specifically, I would ...
I handled / stored / sprayed / unloaded / transported / buried (pick one, two or all) Herbicide (color).
I knew the type of herbicide because... (my NCOIC, Lt., etc. told me that it was Agent Orange / I saw the label on the end of the 55 gallon barrel / I read the shipping paperwork which described what I was handling. Explain what was written on the label or what you were told.)
I came into contact with herbicide xxxx when I... (explain specifically HOW YOU were exposed i.e. sprayed it, spilled it, touched it, wind blew the spray back on you, buried it, brushed your teeth with it, etc.)
Stay to the point. DO NOT state things like "I saw these solders spraying something" because the VA are guaranteed to ask "How did you know for certain what they were spraying..."
I went on Sick-Call because herbicide xxxx (explain in detail what happened and what they did for you on "Sick-Call" for example, How many time(s) were you treated? What did the medic/doc tell you?)
I have attached the following medical records to substantiate my "Sick-Call" reports. (You need to get your military medical records from St. Louis for this one - good luck!)
I mixed herbicides by... (Be specific: state WHAT you mixed it with and by what percentages)
It looked like... (State what color the herbicide was - the color of the liquid AND the barrel band)
I sprayed it by... (If you sprayed herbicides, state HOW you sprayed it - for example back-pack, buffalo turbine, truck etc.)
I was / wasn't told to wear protective clothing / given protective clothing / any caution instructions.
I have a color photograph(s). (If you have a color photograph, DO NOT SEND THEM THE ORIGINAL. Get copies made. They're cheap now. However, state I am in possession of the original photograph.
I have attached copies of the following military documents that SPECIFICALLY describe herbicide xxx coming into xxx, Okinawa or being shipped/transported out of xxx, Okinawa. (Again, DO NOT SEND THE ORIGINAL).
I have the following diseases which my doctor(s) (two is better) have stated that it is "MORE LIKELY THAN NOT" caused by exposure to military herbicides used during the time I served on Okinawa. (STATE "herbicides" - DO NOT SAY "Agent Orange" unless you have PROOF).
The doctors statement will be considered useless if they state "might have, could have, probably had", etc.
Add anything else that is SPECIFIC, FACTUAL and TO THE POINT about how YOU were exposed to herbicides on Okinawa.
If you can, get AT LEAST 3 "buddy statements".
They should be in the same format above that state THEY saw YOU with herbicides.
NOTE - If this is a Witness Statement for YOU from a vet buddy, his/her name SSN, C-# should be at the top and he/she MUST state " I SAW (YOUR NAME) doing...
Finally, do NOT state anything that is your OPINION. Since you are not a doctor or an expert, your opinion will mean nothing to the VA.
For example...If you state that you cleaned aircraft or vehicles that were contaminated with AO, YOU MUST PROVE how you knew what you cleaned WAS contaminated with WHAT (APC's came from DaNang or C-123's flew defoliation missions over Phu Cat, etc.).
If you loaded or unloaded ships, name the ships and dates.
Unless B-52's actually landed in Nam, they won't count just for flying over Vietnam (dropping their load from 30,000 feet, no one would believe they could get contaminated…)
If you need help, drop me a line via Agent Orange Okinawa or contact Joe Sipala directly.
*NB by Jon Mitchell*
This guide was solely put together by Joe to help exposed veterans navigate the labyrinth of the VA - and it was reproduced with his full permission. Any mail you send via the above links will be confidentially 101% between you and Joe... jm