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Take the following actions:

a. Obtain a copy of VA form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative from the VA website: http://www.vba.va.gov/pubs/forms/VBA-21-22-ARE.pdf) and fill in the following blocks:

1) In block 1, writer the name of veteran (individual who served in the military).

2) In block 2, write the VA file number (if available)

3) In block 3A, write “North Carolina Division of Veterans Affairs”

4) In block 3B, write “Veterans Service Officer”

5) In block 4, write the Social Security Number of the veteran

6) In block 7, write the name of the claimant (Medicaid budget unit member eligible for VA benefit – can be veteran, or spouse, parent or child of veteran).

7) In block 8, write the address of the claimant (Medicaid budget unit member eligible for VA benefit -- can be veteran, or spouse, parent or child of veteran).

8) In block 12, write the date of the appointment (must be the same as the date signed in block 16)

9) Have the a/b sign in block 15. VA will not accept the signature of a POA. If the a/b is incapable of signing, the a/b’s “X” is acceptable if witnessed by any two individuals. The witnesses must sign their names next to the “X.”

10) In block 16, write the date signed (must be the same as the date of appointment in block 12)

b. Contact a/b’s identified as being potentially eligible for veteran’s benefits (see D.1. above) using DHB-5026, Notice of Obligation to Apply for Veteran’s Benefits, and VA form 21-22, Appointment Veterans Service Organization as Claimant’s Representative. The DHB-5026 informs the a/b that he must either sign VA form 21-22 or provide proof that he has applied for veteran’s benefits 12 days.