Va Form 21-0958 - Notice Of Disagreement Page 3
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4OMB Approved No. 2900-0791
Respondent Burden: 30 minutes
Expiration Date: 9/30/2017
NOTICE OF DISAGREEMENT
A CLAIMANT OR HIS OR HER DULY APPOINTED REPRESENTATIVE MAY FILE
(DO NOT WRITE IN THIS SPACE)
NOTICE EXPRESSING THEIR DISSATISFACTION OR DISAGREEMENT 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.)
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.
PART I - PERSONAL INFORMATION
V1. VETERAN'S NAME (First, middle initial, last)
2. VA FILE NUMBER
3. VETERAN'S SOCIAL SECURITY NUMBER
C/CSS -
CLAIMANT'S PERSONAL INFORMATION
4. CLAIMANT'S NAME (First, middle initial, last)
5. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
Number and Street
or Rural Route, P.O.
Apt./Unit Number
Box
City, State, ZIP Code
and Country
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?
(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
YES
NO
time period you select below. Please select up to two time periods you are available to receive a phone call.)
8:00 a.m. - 10:00 a.m.
10:00 a.m. - 12:30 p.m.
12:30 p.m. - 2:00 p.m.
2:00 p.m. - 4:30 p.m.
Phone number I can be reached at the above checked time:
PART III - SPECIFIC ISSUES OF DISAGREEMENT
9. NOTIFICATION/DECISION LETTER DATE
10. 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 ADDITIONAL SHEETS IF NECESSARY.
A. Specific Issue of Disagreement
B. Area of Disagreement
C. Percentage (%) Evaluation Sought (If known)
Service Connection
Effective Date of Award
Evaluation of Disability
Other (Please specify)
Service Connection
Effective Date of Award
Evaluation of Disability
Other (Please specify)
Service Connection
Effective Date of Award
Evaluation of Disability
Other (Please specify)
(Continued on next page)
VA FORM
21-0958
JAN 2015
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