Va Form 9 - Appeal To Board Of Veterans' Appeals - Department Of Veterans Affairs

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Form Approved: OMB No. 2900-0085

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. OPTIONAL BVA HEARING

IMPORTANT:

Read the information about this block in paragraph 6 of the attached instructions. This block is used to request a Board of Veterans'

Appeals 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 A BVA HEARING.

I WANT A BVA HEARING BY LIVE VIDEOCONFERENCE.

I WANT A BVA HEARING IN WASHINGTON, DC.

I WANT A BVA HEARING AT A LOCAL VA OFFICE.*

*Due to travel requirements for BVA personnel, selecting Option D may result in a lengthier waiting period for the hearing than the other options. (This option is also not

available at the Washington, DC, or Baltimore, MD, Regional Offices.)

9. THESE ARE THE ISSUES I WANT TO APPEAL TO THE BVA: (Be sure to read the information about this block in paragraph 6 of the attached instructions.)

I WANT TO APPEAL ALL OF THE ISSUES LISTED ON THE STATEMENT OF THE CASE AND ANY SUPPLEMENTAL STATEMENTS OF THE CASE

THAT MY LOCAL VA OFFICE SENT TO ME.

I HAVE READ THE STATEMENT OF THE CASE AND ANY SUPPLEMENTAL STATEMENT OF THE CASE I RECEIVED. I AM ONLY APPEALING THESE

ISSUES:

(List below.)

10. 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.)

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

instructions.)

VA FORM

NOV 2009