What it is
VA Form 21-0781a was the "Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault." VA retired it on June 28, 2024 and folded its function into the updated VA Form 21-0781. If you are searching for 21-0781a, file 21-0781 instead. The legal protections for survivors did not change, only the form number.
When you use it
Use the current 21-0781 for any service connection claim tied to military sexual trauma, sexual harassment, domestic violence in service, hazing, or other personal assault. 38 CFR 3.304(f)(5) recognizes that these events are often not documented in service records and allows evidence from outside those records to corroborate what happened.
What to gather before you fill it out
38 CFR 3.304(f)(5) lists evidence VA will consider when service records are silent:
- Records from law enforcement, rape crisis centers, mental health counselors, hospitals, or physicians.
- Pregnancy tests or tests for sexually transmitted infections around the time of the event.
- Statements from family, roommates, fellow service members, clergy, or counselors.
- Markers of a change after the event: requests for transfer, sudden drop in performance, unexplained anxiety or depression, substance use, episodes of leaving without authority, or relationship changes.
Share only what you are comfortable sharing. A VSO or accredited attorney can help you organize the file.
How to submit
Upload through VA.gov with VA Form 21-526EZ, mail to the Evidence Intake Center, or file through a VSO. VA must tell you about these alternative evidence sources before denying the claim.
Common pitfalls
- Filing the retired 0781a, the correct form is 21-0781.
- Assuming you need a police report. You do not.
- Skipping markers because they feel indirect. Under (f)(5) they carry real weight.
- Going through it alone when a VSO, MST coordinator, or Vet Center counselor can help.
Related forms
21-0781 (current stressor statement), 21-526EZ (claim), 21-4138 (additional statements), 21-22 (representative).
Sources
- https://www.va.gov/find-forms/about-form-21-0781a/
- 38 CFR 3.304(f)(5)