Fillable Form VA 21-0958
The VA 21-0958 form or the Notice of Disagreement form (NOD) must be filled if one disagrees with the VA's decision regarding one's claim for disability compensation.
What is the VA 21-0958 form?
The VA 21-0958 form is a form issued by the Department of Veterans Affairs. This form is used primarily by veterans who disagree with a decision they have received regarding the claim to their military compensation and would want to verify this with the department.
Who can fill out the VA 21-0958 form?
If you are a United States veteran or a duly noted representative of one who wishes to express disagreement with a decision received regarding your claim for disability compensation, then you can fill out this form and submit accordingly.
What do I need to fill out the VA 21-0958 form?
If you are a veteran, you will need your full legal name, social security number (SSN), VA file number, date of birth.
If you are not a veteran but instead filling out this form for one as a duly noted representative, you will need to provide your full legal name, current mailing address, apartment or unit number, city, state or province code, country, zip or postal code, telephone number with the included area code, and your email address but only if you wish to place it.
You will also be asked to provide information regarding your disagreement such as the specific issue of disagreement, area of disagreement, and percentage evaluation sought, if known.
How do I fill out the VA 21-0958 form?
We will be giving you a step-by-step guide on how to fill out the VA 21-0958 form.
Before attempting to fill out the VA 21-0958 form, read through the instructions carefully to identify exactly what information you would need to fill out the form.
Ensure that all information to be placed within should be complete and truthful. Do not leave any box blank unless stated otherwise and follow any format officially given on the form. As this is a government document, it should be treated with the utmost care and attention.
Section I - Veteran’s Identification Information
The information placed in this section will help the Department of Veterans Affairs identify who exactly the veteran in question is.
On the first line of the document, input the veteran’s full legal name. This should be done in the format of first placing the veteran’s first name, followed by his or her middle initial and last name, respectively.
Next, you will be needing to input the social security number (SSN) of the veteran. Afterwards, you will need to input his or her VA file number usually issued by the Department of Veterans Affairs. Finally, you will need to input the veteran’s date of birth. This must following the format of MM - DD - YYYY
Section II - Claimant’s Information
This section will ask for information regarding the claimant whether or not they are a separate entity from the veteran with a disagreement.
If you are a separate individual from the veteran in question and are his or her duly noted representative, then you must write down your full legal name as well in the same format previously.
Regardless of whether you are the veteran or his or her duly noted representative, you must answer the following segments.
In the next line, you must input your current mailing address, complete with the appropriate street and number. Additionally, you will need to provide the corresponding apartment or unit number. Next, you will need to write down the name of the city in which you currently reside in.
Then, write down your state/province of residence. This is followed by your country and then finally your zip code or postal code.
At the very end of this section, indicate your telephone number which should include your area code. Next to this, you can indicate your email address by writing it down, but it is entirely optional and not required for the completion of this form.
Section III - Telephone Contact
This section will ask if you would like to discuss your disagreement over a telephone call.
If you would like to discuss this matter further with a representative, then indicate so by checking the appropriate “Yes or No” box.
If you select the “Yes” option, then you will be asked to select up to two time periods where you are available to receive the call. You can choose among the following time periods:
You must also write down the phone number through which you would like to be contacted.
Section IV - Appeal Process Selection
In this section you will have to indicate which appeal process you would like to select.
You are given the option to choose either the Decision Review Officer (DRO) Review Process or Traditional Appellate Review Process.
Section V - Specific Issues of Disagreement
This section will ask for specific details regarding the issues of disagreement.
Above this section’s header, you will need to place the social security number of the veteran. Do so in the designated boxes.
First you will need to place the date of the notification/decision letter. This is the date of the letter which contained the point of disagreement.
In the designated areas of this section, you must indicate the specific issue/s of disagreement. These must be in paragraph form and show why exactly you view the points as an issue. You will also be asked to check the box corresponding to the area of disagreement. The options are:
You will also be asked to indicate the percentage evaluation sought, only if known.
At the final part of this section, you will be asked to write down in a paragraph or series of paragraphs that explain why you feel the Department of Veterans Affairs incorrectly verified your claim, and list any disagreement(s) not covered. If you need to attach additional sheets, you are encouraged to do so.
If you attached separate pages, please indicate that you did by checking the corresponding “Yes or No” box and then write down how many pages you have attached in the space provided.
Section VI - Certification and Signature
To certify that all information placed within this form is true and correct, affix your signature and write down the date of signing in no specific format.
After completing every section, congratulations, as you have successfully completed the VA 21-0958 form.