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The VA Form 21-0958, known as the Notice of Disagreement, plays a crucial role in the appeals process for veterans seeking to contest decisions made by the Department of Veterans Affairs (VA) regional offices. When a veteran or their authorized representative finds themselves dissatisfied with a VA determination—whether related to a claim for disability benefits or any other decision—they can utilize this form to formally express their disagreement. The document is straightforward yet highly significant; it includes sections where claimants can provide their identifying information, articulate specific issues of contention, and select their preferred method of appeal. Notably, filing a valid Notice of Disagreement is time-sensitive, requiring submission within one year of the decision notification for general claims, and within 60 days for contested claims. Additionally, the form allows veterans to request a call or email from their local regional office, reflecting an intention to foster communication. Careful attention to detail is essential when filling out the form, as neatness can expedite processing and ensure that the claimant's concerns are adequately addressed. Understanding its purpose and processes can empower veterans to effectively advocate for their rights and benefits.

Va 21 0958 Example

OMB Approved No. 2900-0791 Respondent Burden: 15 minutes Expiration Date: 09/30/2021

NOTICE OF DISAGREEMENT

INSTRUCTIONS: A claimant or his or her duly appointed representative may file notice expressing their dissatification or disagreement with an adjudicative determination by the VA regional office. A desire to contest the result will constitute a notice of disagreement (NOD). While special wording is not required, the NOD must be in terms that can be reasonably construed as disagreement with the determination and a desire for appellate review. (Authority 38 U.S.C. 7105) To file a valid NOD, there is a time limit of one year from the date VA mailed the notification of the decision to the claimant. For contested claims, including claims of apportionment, the time limit is 60 days from the date VA mailed the notification of the decision to the claimant.

(DO NOT WRITE IN THIS SPACE)

(VA DATE STAMP)

NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form.

SECTION I - VETERAN'S IDENTIFICATION INFORMATION

1.VETERAN'S NAME (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. VETERAN'S DATE OF BIRTH

Month

 

 

Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II - CLAIMANT'S INFORMATION (If other than veteran)

5.CLAIMANT'S NAME (First, Middle Initial, Last)

6.CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province

Country

City

 

U S

ZIP Code/Postal Code

7.TELEPHONE NUMBER (Include Area Code)

8. E-MAIL ADDRESS (Optional)

SECTION III - TELEPHONE CONTACT

9.WOULD YOU LIKE TO RECEIVE A TELEPHONE CALL OR E-MAIL FROM A REPRESENTATIVE AT YOUR LOCAL REGIONAL OFFICE REGARDING YOUR NOD?

YES NO

(If you answered "Yes," VA will make up to two attempts to call you between 8:00 a.m. and 4:30 p.m. local time at the telephone number and time period you select below. Please select up to two time periods you are available to receive a phone call.)

 

8:00 a.m. - 10:00 a.m.

 

10:00 a.m. - 12:30 p.m.

 

12:30 p.m. - 2:00 p.m.

 

2:00 p.m. - 4:30 p.m.

Phone number I can be reached at the above checked time:

SECTION IV - APPEAL PROCESS ELECTION

10.SELECT ONE OF THE APPEALS PROCESSING METHODS BELOW (See Specific Instructions, Page 2, Section IV for additional information)

Decision Review Officer (DRO) Review Process

Traditional Appellate Review Process

VA FORM

21-0958

SUPERSEDES VA FORM 21-0958, SEP 2015,

Page 3

SEP 2018

WHICH WILL NOT BE USED.

 

 

VETERAN'S SSN

SECTION V - SPECIFIC ISSUES OF DISAGREEMENT

11.NOTIFICATION/DECISION LETTER DATE

12.PLEASE LIST EACH SPECIFIC ISSUE OF DISAGREEMENT AND NOTE THE AREA OF DISAGREEMENT. IF YOU DISAGREE ON THE EVALUATION OF A DISABILITY, SPECIFY PERCENTAGE EVALUATION SOUGHT, IF KNOWN. PLEASE LIST ONLY ONE DISABILITY IN EACH BOX. YOU MAY ATTACH ADDITIONAL SHEETS IF NECESSARY.

A. Specific Issue of Disagreement

 

 

 

B. Area of Disagreement

C. Percentage (%) Evaluation Sought (If known)

 

 

 

 

 

Service Connection

 

 

 

 

 

 

 

 

 

 

 

Effective Date of Award

 

 

 

 

 

 

 

 

 

 

 

Evaluation of Disability

 

 

 

 

 

 

 

 

 

 

 

Other (Please specify below)

 

 

 

 

 

 

 

 

 

 

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Connection

 

 

 

 

 

 

 

 

 

 

 

Effective Date of Award

 

 

 

 

 

 

 

 

 

 

 

Evaluation of Disability

 

 

 

 

 

 

 

 

 

 

 

Other (Please specify below)

 

 

 

 

 

 

 

 

 

 

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Connection

 

 

 

 

 

 

 

 

 

 

 

Effective Date of Award

 

 

 

 

 

 

 

 

 

 

 

Evaluation of Disability

 

 

 

 

 

 

 

 

 

 

 

Other (Please specify below)

 

 

 

 

 

 

 

 

 

 

____________________________

 

 

 

 

 

 

 

 

 

 

 

Service Connection

 

 

 

 

 

 

 

 

 

 

 

Effective Date of Award

 

 

 

 

 

 

 

 

 

 

 

Evaluation of Disability

 

 

 

 

 

 

 

 

 

 

 

Other (Please specify below)

 

 

 

 

 

 

 

 

 

 

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Connection

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date of Award

 

 

 

 

 

 

 

 

 

 

 

 

Evaluation of Disability

 

 

 

 

 

 

 

 

 

 

 

 

Other (Please specify below)

 

 

 

 

 

 

 

 

 

 

 

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13A. IN THE SPACE BELOW, OR ON A SEPARATE PAGE, PLEASE EXPLAIN WHY YOU FEEL WE INCORRECTLY DECIDED YOUR CLAIM, AND LIST ANY DISAGREEMENT(S) NOT COVERED ABOVE:

13B. DID YOU ATTACH ADDITIONAL PAGES TO THIS NOD?

YES NO (If so, how many?)

SECTION VI - CERTIFICATION AND SIGNATURE

I CERTIFY THAT THE STATEMENTS ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

14A. SIGNATURE (Sign in ink)

14B. DATE SIGNED

PENALTY: THE LAW PROVIDES SEVERE PENALTIES WHICH INCLUDE A FINE, IMPRISONMENT, OR BOTH, FOR THE WILLFUL SUBMISSION OF ANY STATEMENT OR EVIDENCE OF A MATERIAL FACT, KNOWING IT TO BE FALSE.

VA FORM 21-0958, SEP 2018

Page 4

Form Characteristics

Fact Name Fact Detail
OMB Approval This form is OMB Approved under No. 2900-0791.
Estimated Completion Time Respondents typically spend about 15 minutes completing this form.
Expiration Date The form expired on September 30, 2021.
Filing Notice A claimant or their representative may file a notice of disagreement to express dissatisfaction with VA decisions.
Time Limits There is a one-year limit to file a notice of disagreement, or a 60-day limit for contested claims.
Method of Completion The form can be completed either online or by hand, with a preference for blue or black ink.
Authority This form operates under the authority of 38 U.S.C. 7105.
Signature Requirement The form must be certified with a signature, confirming the accuracy of the provided information.

Guidelines on Utilizing Va 21 0958

After preparing to fill out the VA Form 21-0958, it’s important to gather the necessary information before you start. Completing this form correctly is essential for expressing your disagreement and ensuring the VA processes your appeal appropriately.

  1. Section I - Veteran's Identification Information:
    • Enter the veteran's name (first, middle initial, last).
    • Fill in the veteran's social security number.
    • Provide the VA file number.
    • Include the veteran's date of birth (month, day, year).
  2. Section II - Claimant's Information:
    • If you are not the veteran, enter your name (first, middle initial, last).
    • Write your current mailing address, including street address, city, state, and ZIP code.
    • Supply your telephone number (including area code).
    • If desired, include your email address.
  3. Section III - Telephone Contact:
    • Indicate if you would like to receive a phone call or email from a local VA representative by marking "YES" or "NO."
    • If "YES," select up to two preferred time periods when you can be reached.
    • Provide a phone number where you can be reached during those times.
  4. Section IV - Appeal Process Election:
    • Select either the Decision Review Officer (DRO) Review Process or the Traditional Appellate Review Process.
  5. Section V - Specific Issues of Disagreement:
    • Enter the date of the notification or decision letter.
    • List each specific issue of disagreement and note the area of disagreement for each issue. If applicable, note the percentage evaluation sought.
    • For each specific disagreement, provide the following information in separate boxes:
      • A brief description of the specific issue.
      • The area where you disagree.
      • The percentage evaluation you desire (if known).
    • In the space provided, explain why you believe the decision was incorrect. Mention any disagreements not covered earlier.
    • Indicate if you have attached additional pages for further explanation, and state how many.
  6. Section VI - Certification and Signature:
    • Certify that the information provided is true to the best of your knowledge by signing the form in ink.
    • Next to your signature, enter the date you signed the form.

With the form completed, you can now submit it to the appropriate VA regional office. Make sure to keep a copy for your records. If you have any additional documents to include, attach them before sending your form. Taking these steps will help ensure your notice of disagreement is processed without unnecessary delays.

What You Should Know About This Form

What is the purpose of the VA Form 21-0958?

The VA Form 21-0958, also known as the Notice of Disagreement (NOD), is used by claimants to express dissatisfaction or disagreement with a decision made by a VA regional office. The form allows the claimant or their appointed representative to formally indicate their intent to contest the decision. While the form does not require special wording, it must be clear enough to demonstrate disagreement with the VA's determination and a desire for appellate review.

What is the deadline for filing the Notice of Disagreement?

To file a valid Notice of Disagreement, claimants have one year from the date the VA mailed the notification of their decision. For contested claims, including those regarding apportionment, the timeframe is reduced to 60 days from the decision notification date. It is crucial for claimants to submit the form within these specified periods to preserve their right to appeal.

Can the VA Form 21-0958 be completed online?

Yes, the VA Form 21-0958 can be completed online. Alternatively, individuals may choose to fill it out by hand. When completing the form by hand, it is important to use blue or black ink and to print legibly. Clear and neat handwriting facilitates the processing of the form, ensuring that all information is accurately captured without confusion.

What information is required on the VA Form 21-0958?

The form requires the following information: the veteran's name, Social Security number, VA file number, and date of birth. If the claimant is not the veteran, their name and contact details must also be included. Additionally, the claimant must specify the issues they disagree with and explain the reasons for their disagreement. This information helps the VA understand the basis for the appeal and ensures that the appropriate review process is followed.

Common mistakes

Completing the VA Form 21-0958 requires attention to detail. Many individuals make mistakes that can delay the processing of their Notice of Disagreement (NOD). One common error is failing to submit the form within the required time limit. Claimants must file their NOD within one year from the date the VA mailed the notification of the decision. This deadline is crucial for ensuring the appeal is considered.

Secondly, providing incomplete or incorrect information can lead to significant issues. Veterans often neglect to fill out their identification information accurately. Mistakes in names, Social Security numbers, or VA file numbers can result in confusion and delays in processing the claim.

Another frequent mistake involves the specific issues of disagreement. Many veterans do not list their disagreements clearly or fail to specify the percentage evaluation sought for disabilities. It is essential to articulate each issue of disagreement in the designated section. Merely stating dissatisfaction without details may not be sufficient for the VA to understand the claimant's concerns.

Additionally, some claimants forget to sign and date the form. Certification is a vital step. Without a signature, the NOD is considered incomplete and may not be processed. This oversight can significantly prolong the appeal process.

Failure to provide contact information is another error that many make. When completing the telephone contact section, the claimant must ensure that the provided phone number is accurate. Missing or incorrect information can prevent the VA from reaching out to discuss the appeal.

Moreover, neglecting to explain why the decision is believed to be incorrect can weaken a case. Claimants should take the time to address this in Section 13A. A well-articulated explanation can assist the VA in understanding the reasons for the disagreement, which is crucial for a successful appeal.

Lastly, not attaching additional pages when necessary is a common mistake. If there is a need for more space to explain disagreements or provide details, claimants should attach separate pages instead of trying to condense information into the limited space provided on the form. This ensures that all relevant details are included, facilitating a more comprehensive review.

Documents used along the form

When submitting the VA Form 21-0958, several other forms and documents may also be required to facilitate the appeal process. Understanding these documents is important for ensuring a complete and effective application. The following is a list of common forms and documents used alongside the VA Form 21-0958:

  • VA Form 21-4138 - This is a Statement in Support of Claim. It allows the claimant to provide additional details or evidence that might support their disagreement with the VA's decision. This form is often used to explain specific issues related to the veteran's claim.
  • VA Form 21-526EZ - This form is used for applying for Disability Compensation. If the veteran is initiating a new claim due to the issues highlighted in the NOD, this form becomes essential. It collects information about the disabilities for which compensation is sought.
  • VA Form 20-0996 - This form is for Higher-Level Review. If a claimant believes that the original decision was wrong, they may opt for this review. It is intended for cases where the claimant is seeking a reassessment of the decision without starting the entire appeal process over again.
  • VA Form 21-22 - This is the Appointment of Veterans Service Organization as Claimant’s Representative. Veterans often use this form to designate a representative to help them navigate the appeal process. Having representation can be beneficial in preparing the NOD effectively.
  • VA Form 10182 - This form is used for Appeals to the Board of Veterans’ Appeals. If a claimant is not satisfied with the outcome of the higher-level review, this form can be filed to initiate an appeal with the Board. It is a crucial step for those wanting to contest the VA's final decision further.

Each of these documents plays a significant role in the appeal process. It is essential to complete them accurately and submit them within specified timeframes to maximize the chances of a favorable outcome. Understanding these requirements can make a substantial difference in navigating the complexities of VA claims effectively.

Similar forms

The VA Form 21-0958, also known as the Notice of Disagreement (NOD), helps individuals express their dissatisfaction with a decision made by the Department of Veterans Affairs (VA). Below is a list of five documents that are similar to this form, along with an explanation of how they relate.

  • VA Form 21-526EZ: This is the application for disability compensation and related compensation benefits. Like the NOD, it is a crucial step in the veterans' claims process. While the 21-526EZ focuses on initiating a claim, the 21-0958 serves to challenge a decision made on that claim.
  • VA Form 21-4138: Known as the statement in support of claim, this document allows claimants to provide a narrative or details that strengthen their case. Similar to the NOD, it offers a means for veterans to communicate issues regarding their claims, albeit for different stages in the process.
  • VA Form 20-0995: The Supplemental Claim application enables veterans to request a review of their claim after a decision has been made. Both this form and the NOD seek to rectify decisions, but the Supplemental Claim focuses on newly gathered evidence or errors in the original claim.
  • VA Form 29-5410: This is the Application for Burial Benefits. While it addresses a different benefit, both this form and the NOD reflect the importance of filing for benefits that impacted veterans or their families. They each serve as a method of appeal or assertion regarding resources entitled to veterans.
  • VA Form 21-0781: The statement in support of claim for PTSD (Post-Traumatic Stress Disorder) relates to the NOD through its function as a means to present evidence of service-related conditions. They share a common purpose of ensuring that veterans' claims are accurately assessed and addressed.

Dos and Don'ts

Filling out the VA Form 21-0958, the Notice of Disagreement, is a critical step in contesting a decision made by the VA. To ensure your submission is successful, follow these guidelines:

  • Do read the instructions carefully before starting. Understanding the requirements will save you time and prevent errors.
  • Don’t wait until the last minute. This form must be submitted within one year of the VA's notification date.
  • Do print legibly using blue or black ink. Clear handwriting helps expedite processing.
  • Don’t use any special wording or forms. Your notice must simply express your disagreement with the VA's decision.
  • Do include all necessary information, such as your name, social security number, and claim specifics.
  • Don’t leave any important sections blank. Each part of the form needs to be completed to ensure it is valid.
  • Do attach any additional sheets if you need more space to explain your disagreement.
  • Don’t forget to sign and date the form. Submitting an unsigned form could delay your appeal.

Misconceptions

  • Misconception 1: The VA 21 0958 form is only for veterans.

    This form can also be filed by a duly appointed representative on behalf of the claimant. Anyone associated with the claim can express disagreement with the decision made by the VA.

  • Misconception 2: There is no time limit for submitting the form.

    In fact, there is a strict time limit. Claimants have one year from the date the VA notifies them of the decision to file the form. For contested claims, the limit is 60 days.

  • Misconception 3: The language in the VA 21 0958 must be formal or use specific legal terms.

    This is not true. The notice of disagreement just needs to express dissatisfaction clearly. Special wording is not necessary, as long as it is understandable and conveys the desire for appeal.

  • Misconception 4: Only one issue can be addressed in the form.

    You can list multiple issues of disagreement. Each issue can be noted in separate sections of the form, allowing claimants to present a comprehensive view of their concerns.

  • Misconception 5: Filling out the form online is not an option.

    In fact, claimants can complete the VA 21 0958 both online or by hand. Choosing the method that works best is well within the claimant's rights.

  • Misconception 6: If additional information is needed, the claim will be automatically rejected.

    This is misleading. Claimants have the opportunity to explain their concerns further in the space provided on the form. They can also attach additional pages if necessary, ensuring their viewpoints are fully expressed.

Key takeaways

Here are some key points to keep in mind when filling out and using the VA 21-0958 form:

  • Ensure you file the form within the specified time limits. You have one year from the date you received the VA's notification for most claims. For contested claims, the window is only 60 days.
  • Clearly express your disagreement. Although special wording is not required, the reason for your disagreement must be understandable. Be specific about what you feel is incorrect.
  • Provide accurate identification information. Double-check that all personal details such as your name, social security number, and address are correct to avoid processing delays.
  • Consider your preferred method of communication. You can choose to receive calls or emails from a representative at your local VA office. Make sure to indicate your availability for phone calls.