VA Form 646
Form Approved, OMB No. 2900-0042
Expiration Date: Feb., 28, 2019
Respondent Burden: 1 Hour
STATEMENT OF ACCREDITED REPRESENTATIVE IN APPEALED CASE
RESPONDENT BURDEN: The information requested on this form is solicited under Sections 7105(a) and (b)(2), Title 38, United States Code.
This form, when completed, is a vehicle which you may use to present information concerning the appeal of the individual whom you represent to the
Board of Veterans' Appeals. It is used by VA and the Board in processing the appeal and by the Board in deciding the appeal. Public reporting burden
for this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Completion of the form is voluntary.
VA may not conduct or sponsor, and the respondent is not required to respond to this collection of information unless it displays a valid OMB Control
Number. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this
burden, to VA Clearance Officer (005R1B), 810 Vermont Avenue, NW, Washington, DC 20420. PLEASE DO NOT SEND APPLICATIONS
FOR BENEFITS TO THE VA CLEARANCE OFFICER.
PRIVACY ACT NOTICE: The information may be disclosed outside of VA as permitted by law and as stated in the notices pertaining to VA's
systems of records which are periodically published in the Federal Register in accordance with the Privacy Act of 1974. Examples of situations in
which the information included in this form might be released to individuals outside of VA include release to the United States Court of Appeals for
Veterans Claims, should the Board of Veterans' Appeals' decision in this case later be appealed to that court; disclosure to a medical expert outside of
VA, should VA determine that a request for an opinion from such an expert under the provisions of Sections 5109 or 7109, Title 38, United States
Code is appropriate; disclosure to law enforcement personnel and security guards in order to alert them to the presence of a dangerous person;
disclosure to law enforcement agencies should a violation of law be indicated; disclosure to a congressional office in order to answer an inquiry from
the congressional office made at your request or the request of the appellant whom you represent; and disclosure to Federal government personnel who
have the duty of inspecting VA's records to make sure that they are being properly maintained. See the Federal Register notices described above for
LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN FILE NO.
All evidence in connection with this appeal has been considered. Please complete and return the statement below on or before the date indicated. If
we do not receive either the statement or a request for extension by that date, it will be necessary for us to certify the appeal to the Board of Veterans'
Appeals on the present record.
REPLY REQUESTED BY (Date)
NAME AND MAIL ROUTING SYMBOL OF ORGANIZATIONAL ELEMENT MAKING REQUEST
TO BE COMPLETED BY ACCREDITED REPRESENTATIVE
NOTE: Section 7105(a) and (b)(2), Title 38, United States Code, give the claimant the right to be represented and give the accredited representative
the right to file claims for the claimant. The presentation of an argument by the accredited representative is voluntary and not necessary for
completion of the appeal. The opportunity or argument is given the accredited representative in order to accord the claimant the right of full
representation at his stage of the appellate process. Failure to file this form may delay the appellate process.
I HEREBY CERTIFY that a statement of the case was furnished; that appellate review is desired on the evidence now of record; and that the issues
for consideration by the Board of Veterans' Appeals are clearly defined.
I REST THE APPEAL ON THE ANSWER TO THE STATEMENT OF THE CASE AND THE HEARING ON APPEAL (If conducted), AND I HAVE NO FURTHER ARGUMENT.
I WISH TO MAKE THE FOLLOWING ARGUMENT TO SUPPLEMENT THE ANSWER TO THE STATEMENT OF THE CASE AND OTHER ARGUMENT OF RECORD:
(ATTACH ADDITIONAL SHEETS, IF NECESSARY)
SIGNATURE AND TITLE OF REPRESENTATIVE
VA FORM 646, JUN 2015, PAGE 2