The veteran whose claim this statement supports. The witness fills this in so VA can attach the statement to the correct file. The veteran provides this information to the witness before they fill the form.

(veteran provides this to witness)

• ×Witness leaving this blank - statement cannot be routed to the right file without the veteran's identifying information.
• ×Witness writing their own name here instead of the veteran's - this section is always about the veteran being supported.

The person writing this statement. Relationship options include: spouse, parent, child, sibling, fellow service member, coworker, neighbor, friend, treating provider, caregiver. VA weighs statements from those with direct knowledge of the specific facts more heavily.

e.g., Jane Smith, spouse, 123 Main St, Phoenix AZ 85001, (602) 555-0100

• ×Vague relationship ("friend") when a more specific relationship exists - "fellow service member, same unit" is stronger.
• ×No contact information - VA may need to verify; missing contact weakens credibility.

The witness describes what they personally observed, heard, or experienced - not what the veteran told them. Strong lay statements are factual and specific: dates, locations, specific behaviors observed, functional limitations witnessed. Under Jandreau v. Nicholson, lay witnesses are competent to identify conditions they directly observe. Under Savage v. Gober, lay evidence of continuity of symptomatology is valid evidence of in-service incurrence.

e.g., I served with John Smith in A Co, 1-504 PIR, 82nd Airborne from 2007-2010. On approximately March 15, 2009 at FOB Shank, Afghanistan, I witnessed John's vehicle strike an IED. I was in the follow vehicle and saw him thrown against the truck frame and limp for weeks afterward. After returning from deployment, I observed John could not run, had difficulty climbing stairs, and complained of constant lower back pain...

• ×Writing what the veteran told you instead of what you personally observed - hearsay is less persuasive than direct observation.
• ×Vague statements ("He seemed to be in pain") without specific examples - "He could not lift boxes over 10 lbs without stopping to rest, which I observed weekly during our shift together" is far stronger.
• ×Covering too many conditions in one statement - one statement per condition or closely related group is cleaner and easier for raters to process.
• ×Not including dates or timeframes - VA needs to determine when symptoms started or continued.

The witness signs under penalty of perjury that the statements are true and accurate to the best of their knowledge. The veteran does NOT sign this form - it is the witness's document.

(witness signature and date)

• ×Veteran signing instead of (or in addition to) the witness - this is the witness's form.
• ×Forgetting to date the signature - VA returns for completion.