Appeal To Board Of Veterans Appeals

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Form Approved: OMB No. 2900-0085
Expiration Date: July 31, 2018
Respondent Burden: 1 Hour
APPEAL TO BOARD OF VETERANS' APPEALS
IMPORTANT: Read the attached instructions before you fill out this form. VA also encourages you to get assistance from your
representative in filling out this form.
1. NAME OF VETERAN (Last Name, First Name, Middle Initial)
2. CLAIM FILE NO. (Include prefix)
3. INSURANCE FILE NO., OR LOAN NO.
4. I AM THE:
VETERAN
VETERAN'S WIDOW/ER
VETERAN'S CHILD
VETERAN'S PARENT
OTHER (Specify)
6. MY ADDRESS IS:
5. TELEPHONE NUMBERS
(Number & Street or Post Office Box, City, State & ZIP Code)
A. HOME (Include Area Code)
B. WORK (Include Area Code)
7. IF I AM NOT THE VETERAN, MY NAME IS:
(Last Name, First Name, Middle Initial)
8. THESE ARE THE ISSUES I WANT TO APPEAL TO THE BOARD: (Be sure to read the information about this block in paragraph 6 of the attached instructions.)
I HAVE READ THE STATEMENT OF THE CASE AND ANY SUPPLEMENTAL STATEMENT OF THE CASE I RECEIVED. I AM ONLY APPEALING THESE
A.
ISSUES:
(List below.)
I WANT TO APPEAL ALL OF THE ISSUES LISTED ON THE STATEMENT OF THE CASE AND ANY SUPPLEMENTAL STATEMENT OF THE CASE
B.
THAT MY LOCAL VA OFFICE SENT TO ME.
9. HERE IS WHY I THINK THAT VA DECIDED MY CASE INCORRECTLY: (Be sure to read the information about this block in paragraph 6 of the attached instructions.)
(Continue on the back, or attach sheets of paper, if you need more space.)
10. OPTIONAL BOARD HEARING
IMPORTANT:
Read the information about this block in paragraph 6 of the attached instructions. This block is used to request an optional Board of Veterans'
Appeals (Board) hearing. DO NOT USE THIS FORM TO REQUEST A HEARING BEFORE VA REGIONAL OFFICE PERSONNEL.
Check one (and only one) of the following boxes:
I DO NOT WANT AN OPTIONAL BOARD HEARING. (Choosing this option often results in the Board issuing its decision most quickly. If you choose, you may write
A.
down what you would say at a hearing and submit it directly to the Board.)
I WANT AN OPTIONAL BOARD HEARING:
BY LIVE VIDEOCONFERENCE AT A LOCAL VA OFFICE. (Choosing this option will add delay to issuance of a Board decision.)
B.
IN WASHINGTON, DC. (Choosing this option will add delay to issuance of a Board decision.)
C.
AT A LOCAL VA OFFICE.* (Choosing this option will add significant delay to issuance of a Board decision.)
D.
*
This option is not available at the Washington, DC, or Baltimore, MD, Regional Offices.
11. SIGNATURE OF PERSON MAKING THIS APPEAL
12. DATE
13. SIGNATURE OF APPOINTED REPRESENTATIVE, IF ANY
14. DATE
(MM/DD/YYYY)
(Not required if signed by appellant. See paragraph 6 of the
(MM/DD/YYYY)
instructions.)
VA FORM
9
JUL 2015

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