Va Form 21 0958 PDF Details

The VA Form 21-0958, known as the Notice of Disagreement (NOD), serves as a critical tool for veterans and their representatives to officially express disagreement with a decision made by the VA regional office regarding their claim. This form initiates the appeals process for a wide range of determinations, from disability evaluations to service connection decisions. Importantly, it must be filed within a specific timeframe - generally one year from the date the decision was mailed to the claimant, with a shorter period of 60 days for contested claims. The form not only allows for listing specific issues of disagreement but also provides veterans the choice between a Decision Review Officer (DRO) review or the traditional appellate review process, tailoring the appeals process to meet their needs. Detailed instructions on the form guide the veterans through each step, ensuring their submission is both valid and clear in its intent to seek appellate review. Additionally, it underscores the importance of submitting true and correct information by highlighting the legal penalties for false submissions. Serving as the beginning step in potentially revising the outcome of a VA claim decision, the VA 21-0958 form is foundational in safeguarding veterans' rights to appeal and seek a reconsideration of benefits and evaluations that significantly impact their lives.

QuestionAnswer
Form NameVa Form 21 0958
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva form do get, va form 21 0958 fillable, va form 21 0958 notice of disagreement, va form 0958

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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

3. VA FILE NUMBER

4. VETERAN'S DATE OF BIRTH

Month

 

 

Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

State/Province

Country

City

 

U S

ZIP Code/Postal Code

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.)

 

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:

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

VA FORM

21-0958

SUPERSEDES VA FORM 21-0958, SEP 2015,

Page 3

SEP 2018

WHICH WILL NOT BE USED.

 

 

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

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

14B. 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.

VA FORM 21-0958, SEP 2018

Page 4

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va notice of disagreement spaces to consider

In the area WOULD YOU LIKE TO RECEIVE A, YES, If you answered Yes VA will make, am am, am pm, pm pm, pm pm, Phone number I can be reached at, SECTION IV APPEAL PROCESS ELECTION, SELECT ONE OF THE APPEALS, Decision Review Officer DRO Review, Traditional Appellate Review, VA FORM SEP, SUPERSEDES VA FORM SEP WHICH, and Page write down the information the system demands you to do.

va notice of disagreement WOULD YOU LIKE TO RECEIVE A, YES, If you answered Yes VA will make, am am, am pm, pm pm, pm pm, Phone number I can be reached at, SECTION IV APPEAL PROCESS ELECTION, SELECT ONE OF THE APPEALS, Decision Review Officer DRO Review, Traditional Appellate Review, VA FORM SEP, SUPERSEDES VA FORM SEP WHICH, and Page blanks to insert

Within the field talking about VETERANS SSN, NOTIFICATIONDECISION LETTER DATE, SECTION V SPECIFIC ISSUES OF, PLEASE LIST EACH SPECIFIC ISSUE, A Specific Issue of Disagreement, B Area of Disagreement C, 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, and Service Connection, it's essential to put down some expected details.

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In the paragraph 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, and A IN THE SPACE BELOW OR ON A, write down the rights and obligations of the sides.

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Prepare the template by analyzing these particular sections: B DID YOU ATTACH ADDITIONAL PAGES, YES, If so how many, I CERTIFY THAT THE STATEMENTS ON, A SIGNATURE Sign in ink, B DATE SIGNED, SECTION VI CERTIFICATION AND, PENALTY THE LAW PROVIDES SEVERE, VA FORM SEP, and Page.

va notice of disagreement B DID YOU ATTACH ADDITIONAL PAGES, YES, If so how many, I CERTIFY THAT THE STATEMENTS ON, A SIGNATURE Sign in ink, B DATE SIGNED, SECTION VI CERTIFICATION AND, PENALTY THE LAW PROVIDES SEVERE, VA FORM SEP, and Page blanks to complete

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