Va Form 21 0958 Pdf Details

VA Form 21 0958 is the application for veterans who wish to use their education benefits to attend a school other than the one they are enrolled in. This form can be used by those who are attending college, graduate school, or pursuing vocational training. The purpose of this form is to provide educational institutions with information about the veteran's eligibility for benefits and the courses they plan to take. It is important that this form be completed accurately and submitted on time, in order to avoid any delays in receiving your benefits. If you have any questions about how to complete this form, or need help submitting it, please contact your nearest Veterans Affairs office.

You'll discover information regarding the type of form you wish to complete in the table. It will tell you just how long it may need to complete va form 21 0958, what parts you will have to fill in, and so forth.

QuestionAnswer
Form NameVa Form 21 0958
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesva emergency notification form, va form your get, va notice of disagreement, vaform21 0958

Form Preview Example

10:00 a.m. - 12:30 p.m.

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

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

 

 

Country

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.

Phone number I can be reached at the above checked time:

12:30 p.m. - 2:00 p.m.

 

2:00 p.m. - 4:30 p.m.

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

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