VA Form 21-0966 Intent to File a Claim for Compensation and/or Pension o

OMB Control No. 2900-0826
Respondent Burden: 5 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,
OR SURVIVORS PENSION AND/OR DIC
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. This
form is used to notify VA of your intent to file for the general benefit(s). For more information, contact us
online through ASK VA: https://ask.va.gov/. Ask us a question online or call us toll-free at 1-800-827-1000
(TTY:711). VA forms are available at www.va.gov/vaforms.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per
box, and completely fill in each applicable check box to expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

3. HAVE YOU EVER FILED A VA CLAIM?

2. SOCIAL SECURITY NUMBER

4. VA FILE NUMBER (If applicable)

YES (If "YES," complete Item 4)
NO
5. DATE OF BIRTH (MM/DD/YYYY)

6. VETERAN'S SERVICE NUMBER (If applicable)

7. MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
Country

State/Province

ZIP Code/Postal Code

8.TELEPHONE NUMBER (Include Area Code)

I agree to receive electronic correspondence from VA in regards
to my claim.

9. EMAIL ADDRESS (If applicable)

Enter International Phone
Number (If applicable)

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION

(Complete this section ONLY if the claimant is NOT the veteran)
10. CLAIMANT'S NAME (First, Middle Initial, Last)

12. HAVE YOU EVER FILED A VA CLAIM?

11. SOCIAL SECURITY NUMBER

13. VA FILE NUMBER (If applicable)

YES (If "YES," complete Item 13)
NO
14. RELATIONSHIP TO VETERAN (Check one)
SPOUSE

CHILD

THIRD-PARTY

FIDUCIARY

15. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY)
VETERAN SERVICE OFFICER

ALTERNATE SIGNER

OTHER (Specify)

16. MAILING ADDRESS (If applicable) (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
State/Province

Country

17.TELEPHONE NUMBER (Include Area Code)

ZIP Code/Postal Code
18. EMAIL ADDRESS (If applicable)

I agree to receive electronic correspondence from VA in regards
to my claim.

Enter International Phone
Number (If applicable)
VA FORM
XXX XXXX

21-0966

SUPERSEDES VA FORM 21-0966, AUG 2018.

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SECTION III: 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.
19. I INTEND TO FILE FOR THE GENERAL BENEFIT(S) CHECKED BELOW: (Check all that apply)
COMPENSATION

PENSION

NOTE: ONLY CHECK THE BOX BELOW IF YOU ARE A SURVIVING DEPENDENT OF THE VETERAN.
SURVIVORS PENSION AND/OR DEPENDENCY AND INDEMNITY COMPENSATION (DIC)

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 at www.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 (VA Form 21-0966) for each general benefit. Please complete as much of this form as possible, as VA cannot
process this form if we cannot identify the claimant and/or veteran.
SECTION IV: DECLARATION OF INTENT AND SIGNATURE
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.
20. SIGNATURE OF VETERAN/CLAIMANT/AUTHORIZED SIGNATURE (REQUIRED)

21. DATE SIGNED (MM/DD/YYYY)

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

Where to Send Correspondence - After completing this form, mail to:
Department of Veterans Affairs
Evidence Intake Center
P.O. Box 4444
Janesville, WI 53547- 4444
PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or
for fraudulent receipt of any document you are not entitled to.

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 the intent of the claimant 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 5 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 21-0966, XXX XXXX

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