Form VA Form 21-0958 VA Form 21-0958 Notice of Disagreement

INFORMATION AND INSTRUCTIONS FOR COMPLETING NOTICE OF DISAGREEMENT (NOD)
IMPORTANT: Please read the information below carefully to help you complete this form quickly and accurately. Some parts of the form also contain notes
or specific instructions for completing that part.
The use of this form is mandatory to initiate an appeal from the decision on disability compensation claims you received. This form has several
key components, which, when filled out completely and accurately, will decrease the amount of time it takes to process your NOD.

FREQUENTLY ASKED QUESTIONS
How do I use this standard Notice of Disagreement (NOD) form?
You must use this form if you wish to indicate that you disagree with a decision you received regarding your claim for disability
compensation. Examples of these decisions may include entitlement to service connection, percentage of evaluation assigned, and
effective date among other things. This form is the only way that you can initiate an appeal from a decision on your claim for disability
compensation.
Should I fill out this form?
You must fill out this form if you disagree with a decision issued by the VA regional office (RO) about your disability compensation claim.
This includes an initial decision, a decision for an increased rating, or any other decision with which you disagree. Only those issues that
you list on this NOD will be considered on appeal. For those issues you do not list on this NOD, you will still have one year from the date
of the decision notification letter to file an appeal for those issues.
Where can I get help?
You can ask the Department of Veterans Affairs (VA) to help you fill out the form by contacting us at 1-800-827-1000. Before you contact
us, please make sure you gather the necessary information and materials, and complete as much of the form as you can.
You can also contact your representative, if applicable, for assistance with completing this form. If you do not already have a
representative, you can find a list of approved Veterans Service Organizations at www.va.gov/vso. You can be represented by a
Veterans Service Organization representative, an attorney-at-law, or "agent". Contact your local RO for assistance with appointing a
representative or visit www.ebenefits.gov.
What should I do when I have finished my NOD?
You should provide your signature in Item 13A and the date signed in Item 13B. Be sure to sign every form you fill out before you send it
to us. If you don't sign the form, VA will return it for you to sign, and it will take longer to process.
Attach any materials that support and explain your NOD.
Mail your NOD to the address included on the VA decision notice letter or take your NOD to your local RO.
Do I need to keep a copy of this NOD form?
It is important that you keep a copy of all completed forms and materials you give to VA.
What constitutes a complete NOD form?
Generally, VA will consider your NOD "complete" if the following information is provided on the form:
(1) Part I - Information to identify the claimant such as name, Social Security Number, or VA claim number.
Please note that it would assist VA if you provide all the personal information in Part I. However, if you provide certain information specific
to the claimant such as the claimant's last name and Social Security Number or VA file number, VA will be able to identify the claimant in
our system and would not necessarily consider this NOD incomplete if other information in Part I, such as the claimant's address and
telephone number, is excluded.
(2) Part IV - Information to identify the specific nature of the disagreement.
Please list the issues or conditions for which you seek appellate review in Item 11 of Part IV. At a minimum, please indicate the specific
issue of disagreement in Item 11A such as "right knee disability" or "Post Traumatic Stress Disorder (PTSD)" and indicate the area of
disagreement in Item 11B by checking the appropriate box. If you disagree with an evaluation of a disability, you may tell us what
percentage evaluation you seek in Item 11C; however, you are not required to indicate the percentage of evaluation sought in Item 11C in
order to complete this form.
(3) Part V - Claimant's signature.
Please be sure to sign the NOD, certifying that the statements on the form are true and correct to the best of the claimant's knowledge and
belief.
IMPORTANT: If you do not provide the above information on this NOD, VA will consider your form incomplete and will request clarification
from you. You must respond to this request for clarification either 60 days from the date of VA's request for clarification or one year from
the date of mailing of the notice of decision of the RO, whichever is later. If you do not provide VA with a completed form within that time
frame, the decision will become final, and you will have to file a new claim.

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SPECIFIC INSTRUCTIONS FOR THE NOD
Part I - Personal Information
Please provide all personal contact information.

Part II - Telephone Contact
Why is VA asking to contact me by telephone?
The purpose of the optional telephone contact is to help process your NOD faster by requesting clarification of any ambiguous information on the form. If
you indicate you wish to be contacted by telephone, VA may make up to two attempts to call you at the telephone number provided during the time slot you
select. It is important to make sure you select a time period you will be available to speak with a RO representative by telephone.

Part III - Election of Decision Review Officer (DRO) Review or Traditional Appellate Review
How does the DRO Review Process work?
A DRO is a senior technical expert who did not participate in the decision being reviewed who is responsible for holding post-decisional hearings, if
requested, and processing appeals. The DRO will conduct a new and complete review of your claim, without deference to the original decision. The DRO
will determine if there is additional evidence necessary to resolve the appeal, may ask you to participate in an informal conference, and/or may pursue
additional evidence. The DRO may issue a new decision that changes the original decision by the RO.
How does the Traditional Appellate Review Process work?
A VA staff member will examine your file and any new evidence that you submit with or after your NOD. The reviewer may change the original decision
based on new evidence or upon a finding of clear and unmistakable error in that decision.
How do I complete this section?
If you wish to elect the DRO Review Process, please check the "Decision Review Officer (DRO) Review Process" box in Item 9. If you wish to continue in
the Traditional Appellate Review Process, please check the "Traditional Appellate Review Process" box in Item 9. Please note that failure to complete this
section will not render the form incomplete.

Part IV - Specific Issues of Disagreement
What date do I enter in the Notification/Decision Letter Date?
You should enter the date stamped on the notification or decision letter you received that you disagree with in Item 10. Please do not enter today's date in
this field. If you need help identifying the date of the notification or decision you disagree with, contact us at 1-800-827-1000.
How do I complete this section?
The purpose of this section is for you to individually identify each area of disagreement that you have with the VA decision notification letter. Please list only
the issues or disabilities with which you disagree. Only those issues that you list on this NOD will be considered on appeal. For those issues you do not list
on this NOD, you will still have one year from the date of the decision notification letter to file an appeal for those issues.
In the Specific Issue of Disagreement column in Item 11A, please individually identify in separate boxes each of the issues with which you disagree.
For example, "left knee condition," "hearing loss," etc.
In the "Area of Disagreement" column, Item 11B, please check the area with which you disagree. For example, if you disagree with the effective date that
VA assigned for a particular benefit, check the "Effective Date of Award" option. If VA granted a benefit, but you disagree with the evaluation that we
assigned, check the "Evaluation of Disability" option. If you were claiming service connection for an injury or disability that you believe to be the result of
your military service, and VA denied that claim, please check the "Service Connection" option. If you are disagreeing with our decision for reasons other
than listed in the "Area of Disagreement" column, please check "Other" and specify your reason.
If you disagree with a disability evaluation that we have assigned and believe that the evidence justifies a specific evaluation, please list the percentage that
you believe the evidence to warrant in the "Percentage of Evaluation Sought If Known" column, Item 11C, within Part IV of the form. To assist, please refer
to our decision notification letter where we indicate what the evidence must show for the evaluation we assigned as well as the next higher evaluation.
Please note that this information is not required and that, even if you limit your appeal by indicating a specific percentage evaluation sought in Item 11C,
evaluation levels above the percentage evaluation sought will be considered in cases where the evidence supports a higher evaluation.
There is extra space provided for you in Item 12A, to explain why you feel VA incorrectly decided your claim, and to list any disagreements
not covered by the form. Please utilize this space to briefly and clearly explain why you disagree with our decision.

Part V - Certification and Signature
Sign and date the NOD, certifying that the statements on the form are true to the best of your knowledge and belief.
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 VA benefits, verification of identity and status, and personnel administration)
as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register.
Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated
with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits
for refusing to provide his or her SSN unless the disclosure of the SSN is required by a 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 maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you
will need an average of 30 minutes to review the instructions, find the information, and complete the 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.
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OMB Approved No. 2900-0791
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX

NOTICE OF DISAGREEMENT
A CLAIMANT OR HIS OR HER DULY APPOINTED REPRESENTATIVE MAY FILE
NOTICE EXPRESSING THEIR DISSATISFACTION 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 WHICH CAN BE REASONABLY CONSTRUED AS DISAGREEMENT WITH
THAT DETERMINATION AND A DESIRE FOR APPELLATE REVIEW. (AUTHORITY:
38 U.S.C. 7105)

(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

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, THIS TIME
LIMIT IS 60 DAYS FROM THE DATE VA MAILED THE NOTIFICATION OF THE
DECISION TO THE CLAIMANT.

PART I - PERSONAL INFORMATION

1. VETERAN'S NAME (First, middle initial, last)

3. VETERAN'S SOCIAL SECURITY NUMBER

2. VA FILE NUMBER
C/CSS -

CLAIMANT'S PERSONAL INFORMATION
4. CLAIMANT'S NAME (First, middle initial, last)

5. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
Number and Street
or Rural Route,
P.O. Box

Apt./Unit Number

City, State, ZIP Code
and Country

6. PREFERRED TELEPHONE NUMBER (Include Area Code)

(

7. PREFERRED E-MAIL ADDRESS

)
PART II - TELEPHONE CONTACT

8. 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:

PART III - APPEAL PROCESS ELECTION
9. SELECT ONE OF THE APPEALS PROCESSING METHODS BELOW (See Specific Instructions, Page 2, Part III for additional information)

Decision Review Officer (DRO) Review Process
Traditional Appellate Review Process

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PART IV - SPECIFIC ISSUES OF DISAGREEMENT
10. NOTIFICATION/DECISION LETTER DATE

11. 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)
____________________________
12A. 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:

12B. DID YOU ATTACH ADDITIONAL PAGES TO THIS NOD?
YES

NO

(If so, how many?)
PART V - CERTIFICATION AND SIGNATURE

I CERTIFY THAT THE STATEMENTS ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
13A. SIGNATURE

13B. 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.
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