Va Form 21-0958 - Notice Of Disagreement
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Department of Veterans Affairs
O~1Il
Appro'cd
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~'l()I)'07'l1
Respondent Burden: 30 nlinules
NOTICE OF DISAGREEMENT
A CLAIMANT OR HIS OR HER DULY APPOINTED
REPRES~E:NT::AT:IV:E::M:Ay:----;;::::===================::i
FILE NOTICE EXPRESSING THEIR DISSATISFACTION OR DISAGREEMENT
(DO NOT WRITE IN THIS SPACE)
WITH AN ADJUDICATIVE DETERMINATION BY THE AGENCY OF ORIGINAL
(VA DATE STAMP)
JURISDICTION. A DESIRE TO CONTEST THE RESULT WILL CONSTITUTE A
NOTICE OF DISAGREEMENT (NOD.)
'MilLE SPECIAL WORDING IS NOT
REQUIRED. THE NOD MUST BE IN TERMS 'MilCH CAN BE REASONABLY
CONSTRUED AS DISAGREEMENT WITH THAT 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, THIS
TIME LIMIT IS 60 DAYS FROM THE DATE VA MAILED THE NOTIFICATION OF
THE DECISION TO THE CLAIMANT.
PART I· PERSONAL INFORMAnON
1 A. VETERAN'S FIRST NAME
1B.
MIDDlE NAME
1 C. LAST NAME
2. VA FILE NUMBER
C/CSS-
4A. CLAIMANTS FIRST AME
5.
STREET ADDRESS
3. VETERAN'S SOCIAL SECURITY NUMBER
1 O.
DAYTIME TELEPHONE NUMBER
11. EVENING TELEPHONE NUMBER
12. EMAIL ADDRESS
PART II· TELEPHONE CONTACT
13. WOULD YOU LIKE TO RECEIVE A TELEPHONE CALL OR EMAIL FROM A REPRESENTATIVE AT YOUR LOCAL REGIONAL OFFICE
REGARDING YOUR NOD?
DYES
0
NO (!fyo"allSlI·tred "res."
J.~"
will make.1p to nroattempls
10
caJfyouben.'een8:00a.m. nnd4:JOp.m. local lime oll/.e ItfdphollelIulllbe,.and
lillie period
)"0/1
select below. Please se/ecr lip
10
nl'o lime periods
)"0/1
are m'oiloble ro receit'e u pirolle cull.)
o
8:00 a.m. - 10:00 a.m.
0
10:00 a.m, - 12:30 p.m.
0
12:30 p.m. - 2:00 p.m.
0
2:00 p.m. - 4:30 p.m.
Phone number I can be reached at the above checked Ifme: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PART III • SPECIFIC ISSUES OF DISAGREEMENT
14. NOTIFICATIONIDECISION LETTER DATE
16. 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 ADDmONAL SHEETS IF NECESSARY.
A. SpecifiC Issue of Disagreement
B. Area of Disagreement
C. Percentage
(%)
Evaluation Sought
(If/mown)
o
Sennce Connection
o
Effective Date of Award
o
Evaluation of Disability
o
Other (Please specify)
o
Service Connection
o
Effective Date of Award
o
Eva/uadon or Disability
o
Other (Please specifY)
o
Servica Connection
o
Effective Date of Award
o
Evaluadon of Disability
o
Other (PI.wsl1 specify)
VA FORM
FEB 2013
'21·0958
(COli/iI/lied
01/ 1It!,"((
page)
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