Fillable Printable VA Form 646

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

further details.

REPRESENTATIVE DATE

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

DATE

VA FORM

JUN 2015(RS)

646

VA FORM 646, JUN 2015, PAGE 2