Va Form 21-0966 - Intent To File A Claim For Compensation And/or Pension, Or Survivors Pension And/or Dic

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OMB Control No. 2900-0826

Respondent Burden: 15 minutes

Expiration Date: 7/31/2018

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION,

OR SURVIVORS PENSION AND/OR DIC

(This Form Is Used to Notify VA of Your Intent to File for the General Benefit(s) Checked Below)

NOTE: Please read the Privacy Act and Respondent Burden below before completing the form.

SECTION I: CLAIMANT/VETERAN IDENTIFICATION

NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to expedite processing of the form.

1. CLAIMANT'S NAME (First, Middle Initial, Last)

2. CLAIMANT'S SOCIAL SECURITY NUMBER

4. VETERAN'S DATE OF BIRTH (MM,DD,YYYY)

3. VA FILE NUMBER (If applicable)

Month

Day

Year

5. VETERAN'S NAME (First, Middle Initial, Last) (If different from claimant)

6. VETERAN'S SOCIAL SECURITY NUMBER

7. VETERAN'S SEX

8. VETERAN'S SERVICE NUMBER (If applicable)

MALE

FEMALE

9. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

City

Apt./Unit Number

State/Province

Country

ZIP Code/Postal Code

10. HAS THE VETERAN EVER FILED A

12. EMAIL ADDRESS (If applicable)

11.TELEPHONE NUMBER (Include Area Code)

CLAIM WITH VA?

YES

SECTION II: GENERAL BENEFIT ELECTION

IMPORTANT: VA may not be able to use this form to establish an effective date for benefits if you do not select one or more of the general benefits listed below.

13. I intend to file for the general benefit(s) checked below: (Choose all that apply)

PENSION

COMPENSATION

NOTE: Only check the box below if you are a surviving dependent of the veteran.

SURVIVORS PENSION AND/OR DEPENDENCY AND INDEMNITY COMPENSATION (DIC)

IMPORTANT: After receiving this form, VA will give you the appropriate application to file for the general benefit you select above. You can also apply for

VA disability compensation online through eBenefits at If you give VA a completed application for the selected general benefit

within one year of filing this form, your completed application will be considered filed as of the date of receipt of this form. Only the first completed

application for each selected general benefit that is received after you file this form will be considered filed as of the date of receipt of this form. You may

indicate your intent to file for more than one general benefit on this form or you may submit a separate intent to file for each general benefit. Please

complete as many fields in Section II as possible. VA cannot process this form if we cannot identify the claimant and veteran.

SECTION III: DECLARATION OF INTENT

By filing this form, I hereby indicate my intent to apply for one or more general benefits under the laws administered by VA. I

acknowledge that: (1) this is not a claim for benefits; (2) I must file a complete application for each general benefit with VA before VA

will process my claim; and (3) a complete application for the same general benefit(s) as indicated on this form must be received within

one year of the date VA receives this form for my application to be considered filed as of the date of this form.

14A. SIGNATURE OF CLAIMANT/AUTHORIZED REPRESENTATIVE

14B. DATE SIGNED (MM,DD,YYYY)

15. NAME OF ATTORNEY, AGENT, OR VETERANS SERVICE ORGANIZATION (Please Print)

(NOTE: This form may only be completed by a Veterans Service Organization, attorney, or agent if a valid power of attorney has been completed.)

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 benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and

Employment Records - VA, published in the Federal Register. Your obligation to respond is required only to preserve a date of claim for an application that is received within one year of receipt of this form. VA uses your Social Security

number to identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is

required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the appropriate application and provide it to the claimant.

RESPONDENT BURDEN: We need this information to determine and to provide the claimant with the appropriate application for VA benefits (38 U.S.C. 5102). Title 38, United States Code, allows us to ask for this information. We

estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You

are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at If desired, you can call

1-800-827-1000 to get information on where to send comments or suggestions about this form.

EXISTING STOCK OF VA FORM 21-0966, JUL 2015,

VA FORM

21-0966

WILL BE USED.

MAR 2017