Form VA Form 21-0966 VA Form 21-0966 Intent to File a Claim for Compensation or Pension, Surv

OMB Control No. 2900-XXXX
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION,
SURVIVORS PENSION, OR OTHER BENEFITS

(This Form Is Used to Notify VA of Your Intent to File for the General Benefit(s) Checked Below)
Note: Please read the Privacy Act and Respondent Burden below before completing the form.

SECTION I: GENERAL BENEFIT ELECTION
IMPORTANT: VA may not be able to use this form to establish an effective date for benefits if you do not
select one or more of the general benefits listed below.
I intend to file for the general benefit(s) checked below: (Choose all that apply)
COMPENSATION

SURVIVORS PENSION OR DEPENDENCY AND INDEMNITY COMPENSATION (DIC)

PENSION

IMPORTANT: After receiving this form, VA will give you the appropriate application to file for the general benefit you select above. You
can also apply for VA disability compensation online through eBenefits at www.ebenefits.va.gov. If you give VA a completed
application for the selected general benefit within one year of filing this form, your completed application will be considered filed as of
the date of receipt of this form. Only the first completed application for each selected general benefit that is received after you file this
form will be considered filed as of the date of receipt of this form. You may indicate your intent to file for more than one general benefit
on this form or you may submit a separate intent to file for each general benefit. Please complete as many fields in Section II as
possible. VA cannot process this form if we cannot identify the claimant and veteran.
1. CLAIMANT'S NAME (Last, first, middle)

SECTION II: CLAIMANT'S IDENTIFICATION

2. CLAIMANT'S SOCIAL SECURITY NUMBER

3. VETERAN/SERVICE MEMBER'S NAME (Last, first, middle) (If different from claimant) 4. VETERAN/SERVICE MEMBER'S SOCIAL SECURITY NUMBER

5. DATE OF BIRTH (MM,DD,YYYY)

6. SEX

7. HAVE YOU EVER FILED A CLAIM WITH VA?

8. VA FILE NUMBER

NO (If "Yes," provide your file number
YES
MALE
FEMALE
in Item 8)
9. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

10. PREFERRED TELEPHONE NUMBER (Include Area Code)

11. PREFERRED E-MAIL ADDRESS (If applicable)

SECTION III: DECLARATION OF INTENT
By filing this form, I hereby indicate my intent to apply for one or more general benefits under the laws administered by VA. I
acknowledge that: (1) this is not a claim for benefits; (2) I must file a complete application for each general benefit with VA before VA
will process my claim; and (3) a complete application for the same general benefit(s) as indicated on this form must be received within
one year of the date VA receives this form for my application to be considered filed as of the date of this form.
12A. SIGNATURE OF CLAIMANT/AUTHORIZED REPRESENTATIVE

12B. DATE SIGNED (MM,DD,YYYY)

13. NAME OF ATTORNEY, AGENT, OR VETERANS SERVICE ORGANIZATION (Please Print)
(NOTE: This form may only be completed by a Veterans Service Organization, attorney, or agent if a valid power of attorney has been completed.)

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required only to preserve a date of claim for an application that is received within one year of receipt of this form. VA uses your Social Security
number to identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or her
SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to
determine the appropriate application and provide it to the claimant.
RESPONDENT BURDEN: We need this information to determine and to provide the claimant with the appropriate application for VA benefits (38 U.S.C. 5102). Title 38, United States Code,
allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB
control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or
suggestions about this form.
VA FORM
XXX 2014

21-0966