VA will obtain or attempt to obtain evidence that supports your claim: • If your claim is for mental health disorder(s) related to combat, personal traumatic event(s), or other traumatic event(s), service treatment records and/or personnel records can be used to support the occurrence of the traumatic event(s). • If your claim is for PTSD related to a personal traumatic event(s), alternative sources of evidence or changes in your behavior such as a change in work performance, substance abuse, economic or social behavioral changes, etc. can also be used to support the occurrence of the traumatic event(s). NOTE: VA will obtain and/or request your service treatment records, personnel records and any other Federal records you identify. Lay testimony can be used: • If you have any individual(s)/witness(es) who know about the personal traumatic event(s) or would have a knowledge of a behavioral change(s) you experienced after the personal traumatic event(s), and wants to provide a statement on your behalf, use VA Form 21-10210, Lay/Witness Statement , and attach it or send it to the address provided in this attachment. If your individual(s)/witness(es) is a veteran, they may be requested to provide their DD Form 214, Certificate of Uniformed Service , or other evidence of service. If you know of evidence not in your possession and want VA to try to get it for you: • Complete and sign VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA) , and • Complete and sign VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA) , identifying any private medical records you wish VA to request for you. If the holder of the evidence declines to give it to VA, asks for a fee to provide it, or otherwise cannot get the evidence, VA will notify you and provide you with an opportunity to submit the information or evidence. Note : It is your responsibility to make sure we receive all requested records that are not in the possession of a Federal department or agency. VA FORM 21-0781, MAR 2024 SUPERSEDES VA FORM 21-0781, JUN 2021. PAGE 1 When To Use This Form: ATTACHMENT TO THE STATEMENT IN SUPPORT OF CLAIMED MENTAL HEALTH DISORDER(S) DUE TO AN IN-SERVICE TRAUMATIC EVENT(S) Evidence That Can Be Used to Support Your Claim: What Form Is Required: Whether or not you complete this form, you must submit one of the following based on the type of claim sought. VA forms are available at www.va.gov/vaforms . please complete and submit VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. please complete and submit VA Form 20-0995, Decision Review Request: Supplemental Claim. If you are filing a new claim or a claim for increased disability compensation .... If you disagree with a prior decision or an evaluation (a claim after an initial claim for the same or similar benefit was previously decided) and have new and relevant evidence .... . Use this form, VA Form 21-0781, Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s) , to provide a statement in support of a claimed mental health disorder(s) (e.g., post-traumatic stress disorder (PTSD), depression, anxiety, bipolar disorder, etc.) due to an in-service traumatic event(s) to include: • Combat traumatic event(s) (e.g., engaged in combat with the enemy, experienced fear of hostile military or terrorist activity, served in an imminent danger area, served as a drone aircraft crew member, etc.) • Personal traumatic event(s) (e.g., sexual assault or sexual harassment, also known as military sexual trauma (MST), physical assault, robbery, stalking, domestic intimate partner abuse, or harassment, etc.) • Other traumatic event(s) (e.g., involvement in car accident or natural disaster, worked on burn ward or graves registration, witnessed the death, injury, or threat to the physical integrity of another person not caused by the enemy, or an experience that involved friendly fire that occurred on a gunnery range during a training mission, etc.) Note: This form is optional and not required. However, completing this form could assist with your claim. VA can use the information you provide to review your military records and other sources of information for evidence to support your claim.

Want to apply electronically ? You can apply online at www.va.gov . If you sign in or create an account, we can prefill parts of your application and save your work in progress. You can also upload all your supporting documents with your claim, then track claim status online. Get started at https://www.va.gov/disability/how-to-file-claim/ . If You Are Mailing Your Completed Form, Send To: Department of Veterans Affairs Evidence Intake Center P.O. Box 4444 Janesville, WI 53547-4444 VA FORM 21-0781, MAR 2024 PAGE 2 You may wish to contact an accredited Veterans Service Officer (VSO) to assist you with your application. For a list of accredited veterans service organizations go to https://www.va.gov/ogc/recognizedvsos.asp . Should you need further assistance with the application process, you may also contact your State Department(s) of Veterans Affairs at https://www.va.gov/statedva.htm . If you have any questions concerning your claim, you may call 1-800-698-2411. If your claim is related to MST, you may also visit the following website to locate the Veterans Benefits Administration (VBA) MST Outreach Coordinator for your area: https://www.benefits.va.gov/benefits/mstcoordinators.asp . For information on Veterans Health Administration (VHA) health care service, visit www.va.gov/health-care/about-va-health-benefits . To learn more about VHA health care services available related to MST, visit www.mentalhealth.va.gov/mst or contact a VHA MST Coordinator. A list is available at www.mentalhealth.va.gov/msthome/vha-mst-coordinators.asp or you can contact your local VA medical facility and ask to speak to the MST Coordinator. If you or someone you know is in crisis, call the Veterans Crisis Line at 988 and then press 1, visit https://www.veteranscrisisline.net/ to chat online, or send a text message to 838255 to receive confidential support 24 hours a day, 7 days a week, 365 days a year. Support for deaf and hard of hearing individuals is available. If You Need Assistance: General Information:

INSTRUCTIONS : Before completing this form, we encourage you to read the Privacy Act and Respondent Burden on page 7. Use this form to provide a statement in support of a claimed mental health disorder(s) due to an in-service traumatic event(s). For more information, you can contact us online through Ask VA: https://ask.va.gov/ or call us toll-free at 1-800-698-2411 (TTY:711). VA forms are available at www.va.gov/vaforms . SECTION I: VETERAN/SERVICE MEMBER'S IDENTIFICATION INFORMATION SECTION II: TRAUMATIC EVENT(S) INFORMATION STATEMENT IN SUPPORT OF CLAIMED MENTAL HEALTH DISORDER(S) DUE TO AN IN-SERVICE TRAUMATIC EVENT(S) VA DATE STAMP (DO NOT WRITE IN THIS SPACE) VA FORM MAR 2024 21-0781 SUPERSEDES VA FORM 21-0781, JUN 2021. PAGE 3 4. DATE OF BIRTH (MM/DD/YYYY) 2. SOCIAL SECURITY NUMBER 3. VA FILE NUMBER (If applicable) 1. VETERAN/SERVICE MEMBER'S NAME (First, Middle Initial, Last) 5. VETERAN'S SERVICE NUMBER (If applicable) 7. E-MAIL ADDRESS (Optional) 6. TELEPHONE NUMBER (Include Area Code) OMB Approved No. 2900-0659 Respondent Burden: 45 minutes Expiration Date: 03/31/2027 NOTE : You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly and insert one letter per box to help expedite processing of the form. Enter International Phone Number (If applicable) 8. SELECT THE TYPE OF IN-SERVICE TRAUMATIC EVENT(S) YOU EXPERIENCED (Check more than one, if applicable) COMBAT TRAUMATIC EVENT(S) PERSONAL TRAUMATIC EVENT(S) (involving MST) (if checked review Section VI) OTHER TRAUMATIC EVENT(S) PERSONAL TRAUMATIC EVENT(S) (not involving military sexual trauma (MST) IMPORTANT : It is helpful, but not required, to complete all applicable sections of the form. Please provide information about where and when the in- service traumatic event(s) occurred. Including this information will help to identify records and sources of information that may support your claim. If you are unable to include this information or only provide approximate dates or locations, VA will still review and consider all the evidence available to support your claim. See the following three examples for guidance on how to complete Items 9A through 9C . SUMMER OF '70 Example 3. Sexually assaulted by drill instructor Example 2. Mugged Example 1. Corpsman on medical ship in Da Nang harbor, Vietnam EXAMPLES OF BRIEF DESCRIPTION OF THE TRAUMATIC EVENT(S) JUNE 2007 EXAMPLES OF DATES THE TRAUMATIC EVENT(S) OCCURRED STATIONED ON U.S.S. XYZ EXAMPLES OF LOCATION OF THE TRAUMATIC EVENT(S) BACK ALLEY IN BIG TOWN, USA FORT XYZ BOOT CAMP 9A. BRIEF DESCRIPTION OF THE TRAUMATIC EVENT(S) (e.g., injury in warfare, physical assault, sexual harassment, witnessed the death or injury of a person, etc.) 9B. LOCATION OF THE TRAUMATIC EVENT(S) (e.g., unit assignment, residence, off-base, duty station or state, if known) 9C. DATE(S) THE TRAUMATIC EVENT(S) OCCURRED (e.g., month(s) or year(s), if known, or approximate dates are acceptable) Note : Briefly summarize the nature of the traumatic event(s) you experienced. While providing this information may be difficult, this information may help identify evidence to support your claim. If you provide name(s) of other individuals who were involved or present during the traumatic event(s), VA will not contact these individual(s). Please know providing name(s) is not required for VA to continue processing your claim. Use Section V: "Remarks" if additional space is needed . 1. 2. 3.

6. CHANGES IN EATING HABITS, SUCH AS OVEREATING OR UNDEREATING, OR SIGNIFICANT CHANGES IN WEIGHT SECTION II: TRAUMATIC EVENT(S) INFORMATION (Continued) VA FORM 21-0781, MAR 2024 PAGE 4 4. 5. SECTION III: ADDITIONAL INFORMATION ASSOCIATED WITH THE IN-SERVICE TRAUMATIC EVENT(S) IMPORTANT : This information will help us identify records or sources of evidence that may support your claim. If you are unable to include this information, VA will still review and consider all the evidence available to support your claim. If additional space is needed, use Section V: "Remarks" . Note : VA understands that in-service traumatic event(s) may not have been reported or documented. In these situations, other information, such as behavioral changes and/or sources of evidence, may be used to support the in-service traumatic event(s). 10. INDICATE ANY BEHAVIORAL CHANGES FOLLOWING THE IN-SERVICE PERSONAL TRAUMATIC EVENT(S) ( Note : Behavioral changes can include but are not limited to the examples listed in Items 10A through 10C. If your traumatic event(s) is combat only, you may skip to Item 11.) A. BEHAVIORAL CHANGES EXPERIENCED FOLLOWING THE TRAUMATIC EVENT(S) (Check any box that applies) B. ADDITIONAL INFORMATION ABOUT THE BEHAVIORAL CHANGES (If applicable) (e.g., approximate time change occurred, documentation, or record) INCREASED/DECREASED VISITS TO A HEALTHCARE PROFESSIONAL, COUNSELOR, OR TREATMENT FACILITY REQUEST FOR A CHANGE IN OCCUPATIONAL SERIES OR DUTY ASSIGNMENT INCREASED/DECREASED USE OF LEAVE CHANGES IN PERFORMANCE OR PERFORMANCE EVALUATIONS EPISODES OF DEPRESSION, PANIC ATTACKS, OR ANXIETY INCREASED/DECREASED USE OF PRESCRIPTION MEDICATIONS INCREASED/DECREASED USE OF OVER-THE- COUNTER MEDICATIONS INCREASED/DECREASED USE OF ALCOHOL OR DRUGS DISCIPLINARY OR LEGAL DIFFICULTIES

SECTION III: ADDITIONAL INFORMATION ASSOCIATED WITH THE IN-SERVICE TRAUMATIC EVENT(S) (Continued) PREGNANCY TESTS AROUND THE TIME OF THE TRAUMATIC EVENT(S) VA FORM 21-0781, MAR 2024 PAGE 5 TESTS FOR SEXUALLY TRANSMITTED INFECTIONS ECONOMIC OR SOCIAL BEHAVIORAL CHANGES CHANGES IN OR BREAKUP OF A SIGNIFICANT RELATIONSHIP C. AS NEEDED, LIST ANY ADDITIONAL BEHAVIORAL CHANGES FOLLOWING THE IN-SERVICE PERSONAL TRAUMATIC EVENT(S) THAT WERE NOT LISTED IN ITEM 10A. 11. WAS AN OFFICIAL REPORT FILED? ( Note : When reporting a sexual assault during military service, the Department of Defense offers two different reporting options, restricted or unrestricted. Knowing the report type will help VA take the necessary steps to obtain a copy of the report. If you are unsure which report was filed, VA may send you a follow up letter with additional information. Submitting a restricted or unrestricted report was not an option prior to 2005.) YES (If "Yes," check the appropriate box below indicating which type of report was filed) NO (If "No," skip to Item 12) RESTRICTED UNRESTRICTED NEITHER POLICE REPORT (Provide location, if known) OTHER (e.g., After Action Report (AAR), incident report, formal complaint, Judge Advocate General (JAG), Criminal Investigative Division (CID), Naval Criminal Investigative Service (NCIS), etc.) 12. POSSIBLE SOURCES OF EVIDENCE FOLLOWING THE TRAUMATIC EVENT(S) (Check all that apply) ( Note : The following sources of evidence may provide additional information for your claim. This list is not all inclusive. If you have any individual(s)/witness(es) who know(s) about the in-service traumatic event(s) or would have knowledge of a behavioral change you experienced after the personal traumatic event(s), and wants to provide a statement on your behalf, use VA Form 21-10210, Lay/Witness Statement . If your individual(s)/witness(es) is a veteran, they may be requested to provide their DD Form 214, or other evidence of service.) A RAPE CRISIS CENTER OR CENTER FOR DOMESTIC ABUSE A COUNSELING FACILITY OR HEALTH CLINIC FAMILY MEMBERS OR ROOMMATES A FACULTY MEMBER CIVILIAN POLICE REPORTS MEDICAL REPORTS FROM CIVILIAN PHYSICIANS OR CAREGIVERS WHO TREATED YOU IMMEDIATELY FOLLOWING THE INCIDENT OR SOMETIME LATER A CHAPLAIN OR CLERGY FELLOW SERVICE MEMBER(S) PERSONAL DIARIES OR JOURNALS NONE OTHER (Specify below): SECTION IV: TREATMENT INFORMATION 13A. HAVE YOU RECEIVED TREATMENT RELATED TO THE IMPACT OF THE TRAUMATIC EVENT(S) LISTED IN ITEM 9A? YES (If "Yes," complete Items 13B through 13E) NO (If "No," skip to Item 14) 13B. IDENTIFY WHERE YOU HAVE RECEIVED TREATMENT (Check all that apply) PRIVATE HEALTHCARE PROVIDER (including non-Federal records) VA VET CENTER COMMUNITY CARE (Paid for by VA) VA MEDICAL CENTER(S) (VAMC) AND COMMUNITY-BASED OUTPATIENT CLINICS (CBOC) DEPARTMENT OF DEFENSE (DOD) MILITARY TREATMENT FACILITY(IES) (MTF) Note : VA has access to VAMC, CBOC, and MTF records. A consent form is not needed. However, if you would like VA to attempt to obtain your private provider (excluding community care (paid for by VA)) or VA Vet Center health records , VA requires your consent by completing VA Form 21-4142, and VA Form 21-4142a. VA forms are available at www.va.gov/vaforms

Note : If VAMC, CBOC, or MTF treatment began from 2005 to present, you do not need to provide dates in Item 13D. SECTION IV: TREATMENT INFORMATION (Continued) VA FORM 21-0781, MAR 2024 PAGE 6 13C. NAME AND LOCATION OF THE TREATMENT FACILITY 13D. DATE(S) OF TREATMENT (Approximate dates are acceptable) (MM-YYYY) 13E. CHECK THE BOX IF YOU DO NOT HAVE DATE(S) OF TREATMENT Don't have date Don't have date Don't have date Note : This section is optional and can be left blank. However, if additional space is needed to fully answer a previous question or if needed, use this section to provide any additional information that you feel is important for us to know that may support your claim. SECTION V: REMARKS 14. REMARKS (If any) SECTION VI: OPTION FOR VETERANS BENEFITS ADMINISTRATION (VBA) TO NOTIFY VETERANS HEALTH ADMINISTRATION (VHA) ABOUT CERTAIN UPCOMING EVENTS DURING THE CLAIM AND/OR APPEAL PROCESS (Note: This section only applies if you checked personal traumatic event(s) (involving MST) in Item 8) 15. If you are filing a claim for compensation for a condition due to a personal traumatic event(s) (involving MST) and you are registered and/or enrolled for VHA health care, you have the option for VBA to electronically notify VHA about certain upcoming event(s) during your claim and/or appeal process. These events are any scheduled compensation and pension (C&P) examination, hearing before the Board of Veterans' Appeals, and any decision notification. When notified, VHA will place an indicator in your medical record to alert VA health care providers that these events are scheduled to occur. Notifications to VHA would only indicate the type of event and potential time frame, not any details specific to your claim. The indicator in your medical record would not identify your claim as MST-related, but at this time, only claimants filing MST-related claims are provided this notification option. For this reason, providers may know that the indicator is in relation to an MST-related claim. The decision to consent, not consent, or revoke prior consent into the automatic notification system will not affect the status or outcome of your claim. If you would like VBA to send these electronic notifications to VHA, please indicate your consent by selecting a check box below. A. I CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL ( Note : I understand that an indicator for these events will appear in my VHA medical record) B. I DO NOT CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL ( Note : I understand that an indicator for these events will not appear in my VHA medical record) C. I REVOKE PRIOR CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENTS RELATED TO MY CLAIM AND/OR APPEAL ( Note : I understand that in the future, notice of these events will no longer appear in my VHA medical record) D. NOT APPLICABLE AND/OR NOT ENROLLED OR REGISTERED IN VHA HEALTHCARE Note : You have the option to modify your previous selection at any time. Mail your correspondence to: Department of Veterans Affairs, Compensation Intake Center, P.O. Box 4444, Janesville, WI 53547-4444 . SECTION VII: CERTIFICATION AND SIGNATURE I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief. 16A.VETERAN/SERVICE MEMBER'S SIGNATURE 16B. DATE SIGNED (MM/DD/YYYY)

SECTION VIII: WITNESSES TO SIGNATURE (Note: Only use this section if the veteran/service member signed Item 16A with an "X") 17A. SIGNATURE OF WITNESS 17B. PRINTED NAME AND ADDRESS OF WITNESS 18A. SIGNATURE OF WITNESS 18B. PRINTED NAME AND ADDRESS OF WITNESS I CERTIFY THAT by signing on behalf of the claimant, that I am a court-appointed representative; OR , an attorney in fact or agent authorized to act on behalf of a claimant under a durable power of attorney; OR , a person who is responsible for the care of the claimant, to include but not limited to a spouse or other relative; OR , a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND , that the claimant is under the age of 18; OR , is mentally incompetent to provide substantially accurate information needed to complete the form, or to certify that the statements made on the form are true and complete; OR , is physically unable to sign this form. I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant if necessary. Examples of evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN); a certificate or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/time stamp; copy of documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and your authority as attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the care of the claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization. 19A. ALTERNATE SIGNER'S SIGNATURE 19B. DATE SIGNED (MM/DD/YYYY) 20A. POA/AUTHORIZED REPRESENTATIVE'S SIGNATURE 20B. DATE SIGNED (MM/DD/YYYY) 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 Veteran Readiness and Employment Records - VA, published in the Federal Register. Completion and submission of this form is voluntary. However, the requested information is important to assist VA in thoroughly researching your military record and other sources to obtain supporting evidence of traumatic event(s) in service. The responses you submit are considered confidential (38 U.S.C. 5701). RESPONDENT BURDEN : An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control Number. The OMB control number for this project is 2900-0659, and it expires 03/31/2027. Public reporting burden for this collection of information is estimated to average 45 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden to VA Reports Clearance Officer at VACOPaperworkReduAct@VA.gov . Please refer to OMB Control No. 2900-0659 in any correspondence. Do not send your completed VA Form 21-0781 to this email address. VA FORM 21-0781, MAR 2024 PAGE 7 NOTE : An alternate signer signature will not be accepted unless a valid VA Form 21-0972, Alternate Signer Certification , is of record or attached to this request. SECTION IX: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (Note: Only required if Item 16A is blank) SECTION X: POWER OF ATTORNEY (POA) SIGNATURE (Note: Only required if Item 16A is blank) I CERTIFY THAT the claimant has authorized the undersigned representative to file this claim on behalf of the claimant and that the claimant is aware and accepts the information provided in this document. I certify that the claimant has authorized the undersigned representative to state that the claimant certifies the truth and completion of the information contained in this document to the best of claimant's knowledge. Note : A POA's signature will not be accepted unless at the time of submission of this claim a valid VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative , or VA Form 21-22a, Appointment of Individual as Claimant's Representative , indicating the appropriate POA is of record with VA. 20C. ACCREDITATION NUMBER 20D. DATE LAST VA FORM 21-22 OR VA FORM 21-22A WAS SUBMITTED (If known)