Form VA 21-0958 for Fillable Template

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 21-0958 JAN 2015 OMB Approved No. 2900-0791 Expiration Date 9/30/2017 NOTICE OF DISAGREEMENT A CLAIMANT OR HIS OR HER DULY APPOINTED REPRESENTATIVE MAY FILE NOTICE EXPRESSING THEIR DISSATISFACTION OR DISAGREEMENT WITH AN ADJUDICATIVE DETERMINATION BY THE AGENCY OF ORIGINAL JURISDICTION. A DESIRE TO CONTEST THE RESULT WILL CONSTITUTE A REQUIRED THE NOD MUST BE IN TERMS WHICH CAN BE REASONABLY CONSTRUED AS DISAGREEMENT WITH THAT DETERMINATION AND A DESIRE FOR APPELLATE REVIEW. AUTHORITY 38 U.S.C. If you do not provide VA with a completed form within that time frame the decision will become final and you will have to file a new claim. VA FORM JAN 2015 21-0958 SPECIFIC INSTRUCTIONS FOR THE NOD Part I - Personal Information Please provide all personal contact information. Part II - Telephone Contact Why is VA asking to contact me by telephone The purpose of the optional telephone contact is to help process your NOD quicker by requesting clarification of any ambiguous information on the form. If you indicate you wish to be contacted by telephone VA may make up to two attempts to call you at the speak with a RO representative by telephone. Please note that it would assist VA if you provide all the personal information in Part I. However if you provide certain information specific to the claimant such as the claimant s last name and Social Security Number or VA file number VA will be able to identify the claimant in our system and would not necessarily consider this NOD incomplete if other information in Part I such as the claimant s address and telephone number is excluded. 2 Part III - Information to identify the specific nature of the disagreement. INFORMATION AND INSTRUCTIONS FOR COMPLETING NOTICE OF DISAGREEMENT NOD IMPORTANT PLEASE READ THE INFORMATION BELOW CAREFULLY TO HELP YOU COMPLETE THIS FORM QUICKLY AND ACCURATELY. O. Box Apt. /Unit Number City State ZIP Code and Country 6. PREFERRED TELEPHONE NUMBER Include Area Code 7. PREFERRED E-MAIL ADDRESS PART II - TELEPHONE CONTACT 8. WOULD YOU LIKE TO RECEIVE A TELEPHONE CALL OR E-MAIL FROM A REPRESENTATIVE AT YOUR LOCAL REGIONAL OFFICE REGARDING YOUR NOD 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 YES NO 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 PART III - SPECIFIC ISSUES OF DISAGREEMENT 9. PREFERRED E-MAIL ADDRESS PART II - TELEPHONE CONTACT 8. WOULD YOU LIKE TO RECEIVE A TELEPHONE CALL OR E-MAIL FROM A REPRESENTATIVE AT YOUR LOCAL REGIONAL OFFICE REGARDING YOUR NOD 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 YES NO 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 PART III - SPECIFIC ISSUES OF DISAGREEMENT 9. NOTIFICATION/DECISION LETTER DATE 10. PLEASE LIST EACH SPECIFIC ISSUE OF DISAGREEMENT AND NOTE THE AREA OF DISAGREEMENT. For example left knee condition hearing loss etc. In the Area of Disagreement column Item 10B please check the area with which you disagree. For example if you disagree with the effective date that VA assigned for a particular benefit check the Effective Date of Award option. If VA granted a benefit but you disagree with the evaluation that we assigned check the Evaluation of Disability option. If you were claiming service connection for an injury or disability that you believe to be the result of your military service and VA denied that claim please check the Service Connection option. If you are disagreeing with our decision for reasons other than listed in the Area of Disagreement column please check Other and specify your reason. If you disagree with a disability evaluation that we have assigned and believe that the evidence justifies a specific evaluation please list the percentage that you believe the evidence to warrant in the Percentage of Evaluation Sought If Known column Item 15C within Part III of the form. To assist please refer to our decision notification letter where we indicate what the evidence must show for the evaluation we assigned as well as the next higher evaluation. There is extra space provided for you in Item 11A to explain why you feel VA incorrectly decided your claim and to list any disagreements not covered by the form. Please utilize this space to briefly and clearly explain why you disagree with our decision. 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. For example if you disagree with the effective date that VA assigned for a particular benefit check the Effective Date of Award option. If VA granted a benefit but you disagree with the evaluation that we assigned check the Evaluation of Disability option. If you were claiming service connection for an injury or disability that you believe to be the result of your military service and VA denied that claim please check the Service Connection option. If you are disagreeing with our decision for reasons other than listed in the Area of Disagreement column please check Other and specify your reason. If you disagree with a disability evaluation that we have assigned and believe that the evidence justifies a specific evaluation please list the percentage that you believe the evidence to warrant in the Percentage of Evaluation Sought If Known column Item 15C within Part III of the form. To assist please refer to our decision notification letter where we indicate what the evidence must show for the evaluation we assigned as well as the next higher evaluation. There is extra space provided for you in Item 11A to explain why you feel VA incorrectly decided your claim and to list any disagreements not covered by the form. Please utilize this space to briefly and clearly explain why you disagree with our decision. 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 VA benefits verification of identity and status and personnel administration as identified in the VA system of records 58/ VA21/22/28 Compensation Pension Education and Vocational Rehabilitation and Employment Records - VA published in the Federal Register.