36C25620Q0256-004.pdf

TYPE OF CONTACT (check one)

REPORT OF CONTACT

ADDRESS OF VETERAN

VA FORM

SEP 1997 (R) 119

LAST NAME-FIRST NAME-MIDDLE NAME OF VETERAN (Type or print)

ADDRESS OF PERSON CONTACTED

PERSON CONTACTED

PERSON WHO CONTACTED YOU

ADDRESS OF PERSON WHO CONTACTED YOU

BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (Continue on page 2 if needed)

EXECUTED BY (Signature and title)

TYPE OF CONTACT (check one)

TELEPHONE NO. OF PERSON CONTACTED

(Include Area Code)

TELEPHONE NO. OF PERSON WHO

CONTACTED YOU (Include area code)

VA OFFICE

TELEPHONE NO. OF VETERAN (Include Area Code)

IDENTIFICATION NOS. (C,XC, SS, XSS, V, K, etc.)

NOTE: As appropriate, once this form is completed it becomes a permanent record in the veteran's folder. Please do not use a pencil to complete this form.

DIVISION OR SECTION

DATE OF CONTACT

PERSONAL TELEPHONE

PERSONAL TELEPHONE

VA FORM 119, SEP 1997 (R), PAGE 2

BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN

C:\Program Files\Adobe\Acrobat 8.0\Designer 8.0\logos\FORMLOGO.jpg Department of Veterans Affairs TYPE OF CONTACT (check one)

REPORT OF CONTACT

REPORT OF CONTACT

ADDRESS OF VETERAN

VA FORMSEP 1997 (R)

V. A. FORM 119, SEPTEMBER 19 97 (R)

LAST NAME-FIRST NAME-MIDDLE NAME OF VETERAN (Type or print)

ADDRESS OF PERSON CONTACTED

PERSON CONTACTED

PERSON WHO CONTACTED YOU

ADDRESS OF PERSON WHO CONTACTED YOU

BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (Continue on page 2 if needed) EXECUTED BY (Signature and title) TYPE OF CONTACT (check one) TELEPHONE NO. OF PERSON CONTACTED(Include Area Code) TELEPHONE NO. OF PERSON WHO CONTACTED YOU (Include area code)

VA OFFICE

TELEPHONE NO. OF VETERAN (Include Area Code) IDENTIFICATION NOS. (C,XC, SS, XSS, V, K, etc.)

NOTE: As appropriate, once this form is completed it becomes a permanent record in the veteran's folder. Please do not use a pencil to complete this form.

NOTE: As appropriate, once this form is completed it becomes a permanent record in the veteran's folder. Please do not use a pencil to complete this form.

DIVISION OR SECTION

DATE OF CONTACT

E:\Pam_Ward\VACO-Reader Ex-David Wachter\QA\vaco-119.xft Pamela Ward 4/9/03

FF99V3.1

Electronic Forms vaco-119

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Report of Contact

IAI

VACO-119

Sept. 1997 119, Report, Contact David Wachter VA Form 119, REPORT OF CONTACT

VA FORM 119, SEP 1997 (R), PAGE 2

V. A. FORM 119, SEPTEMBER 19 97 (R)

BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN