Decision Review Request: Board Appeal (Notice of Disagreement)

OMB Approved No. 2900-0674
Respondent Burden: 30 Minutes
Expiration Date: Feb. 28, 2022

DECISION REVIEW REQUEST: BOARD APPEAL
(NOTICE OF DISAGREEMENT)
PART I - PERSONAL INFORMATION
1. VETERAN'S NAME (First, middle initial, last)

2. VETERAN'S FILE NUMBER

4. IF I AM NOT THE VETERAN, MY NAME IS (First, middle initial, last)

3. VETERAN'S DATE OF BIRTH

5. MY DATE OF BIRTH (If I am not the Veteran)

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

7. MY PREFERRED TELEPHONE
NUMBER (Include Area Code)

8. MY PREFERRED E-MAIL ADDRESS

I AM EXPERIENCING
HOMELESSNESS

9. MY REPRESENTATIVE'S NAME

PART II - BOARD REVIEW OPTION (Check only one)
10. A Veterans Law Judge will consider your appeal in the order in which it is received, depending on which of the following review options you select.
(For additional explanation of your options, please see the attached information and instructions.)
10A. Direct Review by a Veterans Law Judge: I do not want a Board hearing, and will not submit any additional evidence in support of my appeal.
(Choosing this option often results in the Board issuing its decision most quickly.)
10B. Evidence Submission Reviewed by a Veterans Law Judge: I have additional evidence in support of my appeal that I will submit to the
Board with my VA Form 10182 or within the 90 days of the Board's receipt of my VA Form 10182. (Choosing this option will extend the time it
takes for the Board to decide your appeal.)
10C. Hearing with a Veterans Law Judge: I want a Board hearing and the opportunity to submit additional evidence in support of my appeal that I
will provide within 90 days after my hearing. I want the hearing type below (Choosing this option will extend the time it takes for the Board to
decide your appeal.)
Central Office Hearing (I will attend in person in Washington, DC)
Videoconference hearing (I will go to a Regional Office)
Virtual Telehearing (I will attend using an internet-connected device) (Important: Provide your e-mail address and Representative in Part I)

PART III - SPECIFIC ISSUE(S) TO BE APPEALED TO A VETERANS LAW JUDGE AT THE BOARD
11. Please list each issue decided by VA that you would like to appeal. Please refer to your decision notice(s) for a list of adjudicated issues. For each
issue, please identify the date of VA's decision and the area of disagreement (e.g., service connection, disability evaluation, or effective date of award).
Check here if you are including a request for an extension of time to file the VA Form 10182 due to good cause and then attach additional sheets
explaining why you believe there is good cause for the extension.
Check here if you are appealing a denial of benefits by the Veterans Health Administration (VHA)
A. Specific Issue(s)

B. Date of Decision

C. Additional Issue(s)
Check here if you attached additional sheets. Include the Veteran's last name and the file number.

PART IV - CERTIFICATION AND SIGNATURE
I CERTIFY THAT THE STATEMENTS ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
12. SIGNATURE (Appellant or appointed representative) (Ink signature)

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13. 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.

INFORMATION AND DETAILED INSTRUCTIONS FOR COMPLETING
DECISION REVIEW REQUEST: BOARD APPEAL
(NOTICE OF DISAGREEMENT)
NOTE: Use this form ONLY if the VA decision is dated on or after February 19, 2019, and you wish to appeal one or more issues to a Veterans Law
Judge at the Board of Veterans' Appeals. DO NOT USE THIS FORM to submit a Supplemental Claim (if you wish to have additional evidence reviewed
by a VA rater) or request a Higher-Level Review (if you wish to have a new decision by a VA senior reviewer). Instead, please file either a VA Form
20-0995 `Decision Review Request: Supplemental Claim' or a VA Form 20-0996 `Decision Review Request: Higher-Level Review.'
If you have any questions about the filing deadline in your case, ask your representative or your local VA office. Filing on time is very important.
Failing to submit on time could result in you losing your right to appeal.
When should I fill out a VA Form 10182? If you received a decision from a local VA office or a higher-level adjudicator with which you disagree, and
you would like one or more issues to be decided by a Veterans Law Judge, you must fill out and submit a VA Form 10182. You can choose to appeal all
or only some of the issues previously decided, however, ONLY those issues that you list on your VA Form 10182 will be considered on appeal.
How long do I have to submit my VA Form 10182? Your completed VA Form 10182 must be post-marked or received by the Board within one year
(365 days) from the day that your local VA office mailed the notice of the decision unless you are opting into the modernized review system from a
Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC). If you are opting into the modernized review system from an SOC or
SSOC, your completed VA Form 10182 must be post-marked or received by the Board within 60 days of the SOC or SSOC letter or within one year of
the date of the decision by agency of original jurisdiction, whichever is later. If you do not provide all the information requested in the VA Form 10182,
VA will consider your form incomplete and will contact you to request clarification and explain your options.
Contested Claim: If you are one of multiple people claiming the right to the same benefit, your completed VA Form 10182 must be post-marked or
received by the Board within 60 days from the day that your local VA office mailed the notice of the decision. VA will notify you and provide additional
information if you are a party to a contested claim.
What are my options for the Board's review? You must choose one of three options for how a Veterans Law Judge will review the issue(s) on appeal.
Determine which of the below options best fits your situation. You can select different Board review options for different issues. However, if you choose
to do so, you must submit a separate VA Form 10182 for each Board review option and list the issues that you want reviewed under that option.
REVIEW OPTION

DESCRIPTION

Direct Review

- Choose this option if you do not want to submit additional evidence, and you do not want a hearing with a Veterans Law
Judge.
- The Veterans Law Judge and Board team will review the issue(s) you appealed, and make a new determination based on
the evidence of record at the time of the decision on appeal.
- Choosing this option will often result in a Veterans Law Judge at the Board being able to issue its decision most quickly.

Evidence Submission

- Choose this option if you want to submit additional evidence, but you do not want to have a hearing with a Veterans Law
Judge.
- The Veterans Law Judge and Board team will review the issue(s) you appealed, considering the evidence of record at the time
of the decision on appeal, along with any additional evidence that you submit with your VA Form 10182 or within 90 days
after VA's receipt of your VA Form 10182.
- After 90 days, any additional evidence added to your claim will not be considered by the Board.
- Choosing this option will extend the time it takes for the Board to decide your appeal.

Hearing Request

- Please note that a Board hearing is optional, and may increase the wait time for a Board decision.
- Choose this option if you want a hearing with a Veterans Law Judge, which includes the option to submit additional
evidence.
- The Board will contact you to schedule your hearing and provide additional information.
- After your hearing, the Veterans Law Judge and Board team will review the issue(s) you appealed, considering the
evidence at the time of the decision on appeal, along with your hearing testimony and any additional evidence that you
submit within 90 days after the hearing.
- If you do not appear for your scheduled hearing, the Veterans Law Judge and the Board team will review any evidence you
submit within 90 days following the date of the scheduled hearing. If you choose to withdraw your hearing request, the
Veterans Law Judge and the Board team will review evidence you submit within 90 days of the Board's receipt of your
hearing withdrawal request.
- Choosing this option will extend the time it takes for the Board to decide your appeal.

Find more information on the review options at va.gov/decision-reviews.
Where can I get help with filing my appeal? A Veterans Service Organization or a VA-accredited attorney or agent can represent you or provide
guidance. Contact your local VA regional office for assistance or visit: va.gov/ogc/accreditation.asp.
Where do I submit my VA Form 10182 once I have completed it? When you have completed the VA Form 10182, signed and dated it, you must send
it to the Board at the address below:
Board of Veterans' Appeals
P.O. Box 27063
Washington, DC 20038
What if I want to modify my VA Form 10182? You may make a request to modify your VA Form 10182 for the purpose of selecting a different review
option in Part II. Any such request must be made by submitting a new VA Form 10182 form to the Board within one year (365 days) from the date of
mailing of the notice of decision on appeal or within 60 days of the Board's receipt of the VA Form 10182, whichever is later. You cannot request to
modify your VA Form 10182 if you have already submitted evidence to the Board or testified at a hearing with a Veterans Law Judge.

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OVERVIEW OF NOTICE OF DISAGREEMENT FORM SECTIONS
If you decide to appeal to a Veterans Law Judge at the Board, these instructions will help you complete your VA Form 10182.
Part I - PERSONAL INFORMATION Please provide all the personal information in Part I. If desired, you may also enter the claimant's prefix (such as
“Mr.” or “Ms.”) and/or suffix (such as “Jr.” or “Sr.”). If your address has changed recently or will change soon, please notify your local VA office. If you are
homeless, please check the box in item 6. If you wish to include multiple addresses, you may attach additional sheets to the form, explaining how you
would like VA to contact you. Please check the box in Part III, Block 11C to indicate additional sheets are attached. Please include the Veteran's last
name and the file number on any additional sheets.
Part II - REVIEW OPTION You must check one, and only one, of the boxes in Part II, Block 10, to choose how you would like the Board to review the
issues identified in Part III. The Board will place your appeal onto a list for consideration in the order it was received.
You can select different Board review options for different issues. However, if you choose to do so, you must submit a separate VA Form 10182 for each
Board review option and list the issues that you want reviewed under that option.
Box 10A - Direct Review by a Veterans Law Judge: Check this box if you do not want to submit additional evidence and you do not want a
Board hearing.
Box 10B - Evidence Submission Reviewed by a Veterans Law Judge: Check this box if you do not want a Board hearing, but you do want
to submit additional evidence with this VA Form 10182 or within 90 days following VA's receipt of your VA Form 10182.
Box 10C - Hearing With a Veterans Law Judge: Check this box if you want a Board hearing with a Veterans Law Judge, which includes the
option to submit additional evidence at your hearing or within 90 days following the hearing, if it is held. If you do not appear for your
scheduled hearing, you may submit evidence within 90 days following the date of the scheduled hearing. If you later choose to withdraw your
hearing request, you may submit evidence within 90 days of the Board's receipt of your hearing withdrawal request.
If you have already submitted a VA Form 10182, and wish to change your Board Review Option, please fill out this form completely, indicating your new
choice in Part II.
Part III - SPECIFIC ISSUE(S) BEING APPEALED TO THE BOARD List the issue(s) you would like the Board to review in Part III, Block 11A, and the
date of your decision notice in Part III, Block 11B. Please refer to your decision notice for a list of adjudicated issues. If you want to appeal more issues,
you may attach additional pages as needed. Please check the box in Part III, Block 11C to indicate additional sheets are attached. Please include the
Veteran's last name and the file number on any additional sheets.
Upon receipt of a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC) in the legacy appeals system, you may elect to continue
your appeal either in the legacy appeals system or in the modernized review system. For more information, please review the instructions provided on
the `VA Form 20-0998: Your Rights to Seek Further Review of Our Decision,' which was attached to your decision notice letter.
Extension Requests Check the box in Part III, Block 11, if you are including a request for an extension of time to file the VA Form 10182 due to good
cause and attach additional sheets indicating why you believe there is good cause for the extension. Please include the Veteran's last name and the file
number on any additional sheets.
Part IV - CERTIFICATION AND SIGNATURE Please sign and date the VA Form 10182, certifying that the statements on the form are true to the best of
your knowledge and belief. An appointed representative may sign on the behalf of the appellant.
WHAT IF I WANT TO ADD ADDITIONAL INFORMATION? If you want to provide any additional information to VA, including why you believe that VA
previously decided one or more issues incorrectly, you may check the box in Part III, Block 11C and attach additional sheets to the form. Please include
the Veteran's last name and the file number on any additional sheets. For each issue, please make sure to identify the date of VA's decision. The Board
will consider argument submitted with any VA Form 10182.
PRIVACY ACT STATEMENT: Our authority for asking for the information you give to us when you fill out this form is 38 U.S.C. 7105(d)(3), a Federal
statute that sets out the requirement for you to submit a formal appeal to complete your appeal on a VA benefits determination. You use this form to
present your appeal to the Board of Veterans' Appeals (Board). It is used by VA in processing your appeal and it is used by the Board in deciding your
appeal. Providing this information to VA is voluntary, but if you fail to furnish this information VA will close your appeal and you may lose your right to
appeal the benefit determinations you told us you disagreed with. The Privacy Act of 1974 (5 U.S.C. 552a) and VA's confidentiality statute (38 U.S.C.
5701), as implemented by 38 C.F.R. 1.526(a) and 1.576(b), require individuals to provide written consent before documents or information can be
disclosed to third parties not allowed to receive records or information under any other provision of law. However, the law permits VA to disclose the
information you include on this form to people outside of VA in some circumstances. Information about that is given in notices about VA's "systems of
records" that are periodically published in the Federal Register as required by the Privacy Act of 1974. Examples of situations in which the information
included in this form might be released to individuals outside of VA include release to the United States Court of Appeals for Veterans Claims, if you later
appeal the Board's decision in your case to that court; disclosure to a medical expert outside of VA, should VA exercise its statutory authority under 38 U.
S.C. 5109 or 7109, to ask for an expert medical opinion to help decide your case; disclosure to law enforcement personnel and security guards in order
to alert them to the presence of a dangerous person; disclosure to law enforcement agencies should the information indicate that there has been a
violation of law; disclosure to a congressional office in order to answer an inquiry from the congressional office made at your request; and disclosure to
Federal government personnel who have the duty of inspecting VA's records to make sure that they are being properly maintained. See the Federal
Register notices described above for further details.
RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond to, this collection of information unless it
displays a valid Office of Management and Budget (OMB) Control Number. The information requested is approved under OMB Control Number
(2900-0674). Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this burden to: VA Clearance
Officer (008), 810 Vermont Ave., NW, Washington, DC 20420. DO NOT send requests for benefits to this address.

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