Va Form 21-0958 - Notice Of Disagreement - Department Of Veterans Affairs
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2OMB Approved No. 2900-0791
Respondent Burden: 30 minutes
Expiration Date: 09/30/2018
NOTICE OF DISAGREEMENT
A CLAIMANT OR HIS OR HER DULY APPOINTED REPRESENTATIVE MAY FILE
NOTICE EXPRESSING THEIR DISSATISFACTION OR DISAGREEMENT WITH AN
(DO NOT WRITE IN THIS SPACE)
ADJUDICATIVE DETERMINATION BY THE VA REGIONAL OFFICE. A DESIRE TO
(VA DATE STAMP)
CONTEST THE RESULT WILL CONSTITUTE A NOTICE OF DISAGREEMENT
(NOD.) WHILE SPECIAL WORDING IS NOT 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. 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.
NOTE: You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form.
PART I - PERSONAL INFORMATION
1. VETERAN'S NAME (First, middle initial, last)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VA FILE NUMBER
C/CSS -
CLAIMANT'S PERSONAL INFORMATION
4. CLAIMANT'S NAME (First, middle initial, last)
5. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
City
U S
State/Province
Country
ZIP Code/Postal Code
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?
YES
NO
(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
time period you select below. Please select up to two time periods you are available to receive a phone call.)
10:00 a.m. - 12:30 p.m.
2:00 p.m. - 4:30 p.m.
8:00 a.m. - 10:00 a.m.
12:30 p.m. - 2:00 p.m.
Phone number I can be reached at the above checked time:
PART III - APPEAL PROCESS ELECTION
9. SELECT ONE OF THE APPEALS PROCESSING METHODS BELOW (See Specific Instructions, Page 2, Part III for additional information)
Decision Review Officer (DRO) Review Process
Traditional Appellate Review Process
VA FORM
21-0958
Page 3
SEP 2015
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