Va Form 21 0958 – Fill Out and Use This PDF

In Section I, Veteran's Identification Information, enter the Veteran's Name (First, Middle Initial, Last) in Box 1.

Enter the Veteran's Social Security Number in Box 2 and the VA File Number in Box 3.

Enter the Veteran's Date of Birth in Box 4.

In Section II, Claimant's Information, if other than veteran, enter the Claimant's Name (First, Middle Initial, Last) in Box 5.

For a claimant other than the veteran, enter the Current Mailing Address in Box 6: Number and street or rural route, P.O. Box, City, State, ZIP Code and Country.

For a claimant other than the veteran, enter the Telephone Number (Include Area Code) in Box 7. The E-mail Address in Box 8 is optional.

In Section III, Telephone Contact, Box 9: Would you like to receive a telephone call or e-mail from a representative at your local regional office regarding your NOD? Check YES or 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. Please select up to two time periods you are available to receive a phone call.

Enter the phone number you can be reached at the checked time.

In Section IV, Appeal Process Election, in Box 10, select one of the appeals processing methods: Decision Review Officer (DRO) Review Process or Traditional Appellate Review Process.

In Section V, Specific Issues of Disagreement, enter the Notification/Decision Letter Date in Box 11.

In Box 12, please list each specific issue of disagreement under A. Specific Issue of Disagreement and note the area of disagreement under B. Area of Disagreement.

Under B. Area of Disagreement, the areas are Service Connection, Effective Date of Award, Evaluation of Disability and Other (Please specify).

If you disagree on the evaluation of a disability, specify percentage evaluation sought, if known, under C. Percentage (%) Evaluation Sought (If known).

Please list only one disability in each box. You may attach additional sheets if necessary.

In Box 13A, or on a separate page, please explain why you feel the claim was incorrectly decided, and list any disagreement(s) not covered.

In Box 13B, check YES or NO: Did you attach additional pages to this NOD? If so, how many?

In Section VI, Certification and Signature, sign in ink in Box 14A and enter the date signed in Box 14B.

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.

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.

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.