Fillable Va Form 8 - Certification Of Appeal printable pdf download

Va Form 8 - Certification Of Appeal

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CERTIFICATION OF APPEAL

1A. NAME OF APPELLANT (If other than veteran)

1B. RELATIONSHIP TO VETERAN

2. FILE NO.

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN

4. INSURANCE FILE NO. OR

LOAN NO. (If pertinent)

THE APPEAL IS FOR (State the question(s) at issue clearly and concisely.)

5A. SERVICE CONNECTION FOR

5B. DATE OF NOTIFICATION OF

ACTION APPEALED

6A. INCREASED RATING FOR

6B. DATE OF NOTIFICATION OF

ACTION APPEALED

7A. OTHER

7B. DATE OF NOTIFICATION OF

ACTION APPEALED

8A. APPELLANT REPRESENTED IN THIS APPEAL BY (Name of organization, attorney or agent)

8B. ONE OF THE FOLLOWING IS ON FILE AS AUTHORITY FOR RECOGNIZING SUCH REPRESENTATIVE IN THIS APPEAL

8C. IF AGENT DESIGNATED, IS

HE/SHE ON ACCREDITED LIST?

POWER OF ATTORNEY (VA Form 21-22 or VA Form 21-22a)

CERTIFICATION THAT VALID POWER OF ATTORNEY IS IN

YES

ANOTHER VA FILE (If so, specify file)

9A. IF REPRESENTATIVE IS SERVICE ORGANIZATION, IS VA FORM 646, OR

9B. IF VA FORM 646 IS NOT OF RECORD, EXPLAIN

EQUIVALENT, OF RECORD?

YES

10A. WAS HEARING REQUESTED?

10B. IF HELD, IS TRANSCRIPT IN FILE?

YES

10C. IF REQUESTED BUT NOT HELD, EXPLAIN

11A. ARE CONTESTED CLAIMS PROCEDURES APPLICABLE IN THIS CASE?

11B. HAVE THE REQUIREMENTS OF 38 U.S.C. 7105a BEEN FOLLOWED?

YES

NO (If "YES," complete item 11B).

YES

12A. DATE STATEMENT OF THE CASE FURNISHED

12B. SUPPLEMENTAL STATEMENT OF THE CASE

REQUIRED AND FURNISHED

NOT REQUIRED

13. RECORDS TO BE FORWARDED TO BOARD OF VETERANS' APPEALS

CF OR XCF

R&E F

LOAN GUAR. F

OUTPATIENT F

X-RAYS

INACTIVE CF

TRAINING SUB-F

INSURANCE F

HOSPITAL COR.

SLIDES

DEP. ED. F (Ch. 35)

DENTAL F

CLINICAL REC.

TISSUE BLOCKS

OTHER (Specify)

14. REMARKS (Continue on reverse)

CERTIFICATION: It is hereby certified that all material evidence is of record, that all contentions advanced by and on behalf of the appellant have been considered under

all pertinent laws, and the issues determined.

15. NAME AND LOCATION OF CERTIFYING OFFICE

16. ORGANIZATIONAL ELEMENT CERTIFYING APPEAL

17A. SIGNATURE OF CERTIFYING OFFICIAL

17B. TITLE

17C. DATE

18A. SIGNATURE OF MEDICAL MEMBER (Insurance use only)

18B. TITLE

18C. DATE

VA FORM

SUPERSEDES VA FORM 8, OCT 1992,

JUN 2008