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
4. VETERAN'S DATE OF BIRTH
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
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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.)
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8:00 a.m. - 10:00 a.m. |
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10:00 a.m. - 12:30 p.m. |
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12:30 p.m. - 2:00 p.m. |
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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
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VA FORM |
21-0958 |
SUPERSEDES VA FORM 21-0958, SEP 2015, |
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SEP 2018 |
WHICH WILL NOT BE USED. |
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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 |
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B. Area of Disagreement |
C. Percentage (%) Evaluation Sought (If known) |
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Service Connection |
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Effective Date of Award |
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Evaluation of Disability |
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Other (Please specify below) |
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Service Connection |
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Effective Date of Award |
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Evaluation of Disability |
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Other (Please specify below) |
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Service Connection |
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Effective Date of Award |
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Evaluation of Disability |
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Other (Please specify below) |
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Service Connection |
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Effective Date of Award |
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Evaluation of Disability |
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Other (Please specify below) |
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Service Connection |
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Effective Date of Award |
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Evaluation of Disability |
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Other (Please specify below) |
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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)
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 |
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