Va Form 21-0958 - Notice Of Disagreement (Page 2 of 2) in pdf

Va Form 21-0958 - Notice Of Disagreement Page 2

PART III - SPECIFIC ISSUES OF DISAGREEMENT

(Co"ti""ed)

Specific Issue of Disagreement

B. Area of Disagreement

C. Percentage (%) Evaluation Sought

(lfkllolVn)

Sennee Connection

Effective Date of Award

Evaluation of Disability

Other (Please specifY)

Sennee Connection

Effective Date of Award

Evaluatlon of Disability

Other (Pltase specifY)

16A. 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:

16B. DID YOU ATIACH ADDITIONAL PAGES TO THIS NOD?

DYES

Ilfso.ltow mOllY?)

PART IV - CERTIFICATION AND SIGNATURE

I CERTIFY THAT THE STATEMENTS ON THtS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

17A.

SIGNATURE

17B.

DATE SIGNED

PENAL TV: 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 FCRM 21-0958. FEB 2013

Va Form 21-0958 - Notice Of Disagreement Page 2