Va Form 21-0958 - Notice Of Disagreement Page 4

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(Continued)
PART III - SPECIFIC ISSUES OF DISAGREEMENT
C. Percentage (%) Evaluation Sought (If known)
A. Specific Issue of Disagreement
B. Area of Disagreement
Service Connection
Effective Date of Award
Evaluation of Disability
Other (Please specify)
Service Connection
Effective Date of Award
Evaluation of Disability
Other (Please specify)
11A. 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:
11B. DID YOU ATTACH ADDITIONAL PAGES TO THIS NOD?
(If so, how many?)
YES
NO
PART IV - CERTIFICATION AND SIGNATURE
I CERTIFY THAT THE STATEMENTS ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
12A. SIGNATURE
12B. DATE SIGNED
PENALTY: 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 FORM 21-0958, JAN 2015

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