BUDDY / WITNESS STATEMENT TEMPLATE (Lay Statement) For a spouse, family member, battle buddy, coworker, or friend to write about what they witnessed. File it on VA Form 21-10210. Fill the brackets, cut them, sign it. One writer per statement. WHAT MAKES A LAY STATEMENT WORK A rater opens the file and the file only knows the inside of an appointment. A witness fills in everything between the appointments. The job of this page is to put the worst days into specifics a rater can score. Two rules: 1. Write what you SAW, not what you concluded. "He stops halfway up the stairs to catch his breath" beats "He has breathing problems," because the rater can picture the landing where he stops. 2. A dated example beats a general one. The rater cannot wave off a date. ------------------------------------------------------------------------------- STATEMENT IN SUPPORT OF CLAIM Regarding veteran: [VETERAN'S FULL NAME] Condition this statement is about: [CONDITION] Date: [DATE] 1. WHO I AM (my basis of knowledge) My name is [WRITER'S FULL NAME]. I am the veteran's [RELATIONSHIP, e.g. spouse, mother, fellow service member]. I have known the veteran for [NUMBER] years. [For a battle buddy: I served with the veteran in the [UNIT] from [DATES] and was present for the events described below.] I see the veteran [HOW OFTEN, e.g. every day / several times a week], which is why I can speak to what follows. 2. WHAT I HAVE PERSONALLY OBSERVED [Concrete, witnessed examples. Not opinions, not diagnoses. The kind of detail that lands: - "I have watched him [SPECIFIC THING HE CANNOT DO]." - "I have had to [WHAT YOU DO TO HELP, e.g. help him put his socks on because he cannot bend that far]." - "I hear him [WHAT HAPPENS AT NIGHT / DURING A FLARE]."] 3. HOW OFTEN IT HAPPENS AND HOW BAD IT GETS Frequency: [HOW OFTEN you witness the bad episodes] Severity at worst: [WHAT HE CANNOT DO AT ALL when it is at its worst] Change over time: [how he was before vs. now, and roughly when it shifted] 4. HOW IT AFFECTS HIS DAILY LIFE [What the condition has taken from him that you have watched firsthand: work, chores, time with family, activities he gave up, his mood, his sleep.] 5. SPECIFIC DATED EXAMPLES (the strongest part) - On [DATE], [WHAT YOU WITNESSED, e.g. he could not attend a family event because of the condition]. - On [DATE], [SECOND CONCRETE, DATED THING YOU SAW]. 6. FOR A BATTLE BUDDY: THE IN-SERVICE EVENT [If this statement establishes something that happened in service and never made it into the records, describe it here. What happened, where, roughly when, who was there, and that you witnessed it directly. This is how an event with no injury report still gets on the record.] 7. CERTIFICATION I certify that the statements above are true and correct to the best of my knowledge and belief. Signature: _______________________________ Date: ____________ ------------------------------------------------------------------------------- USING THE AI TO BEAT THE BLANK PAGE The reason this never gets written is the blank page. Have the analyst run the interview: tell it to ask the writer specific questions about observable symptoms, frequency, severity, and daily impact, let the writer answer in their own words, then have it draft this statement in the writer's voice. The writer reads it, fixes anything that does not sound like them, and signs. Confirm the form number and certification language against VA.gov before anyone signs.