The 9 Most Common VA Forms and Tips on Using Them

,
The 9 Most Common VA Forms and Tips on Using Them

Every veteran who has filed a claim for VA benefits knows about the dizzying battery of VA forms. There are hundreds of VA forms available. Does it matter what you write in VA form 21-4138? Is VA form 21-0996 even necessary? Should you fill out VA form 21-0781 or 21-0781a?

Knowing which VA forms to use and how to fill them out can help prevent time-consuming, costly mistakes. Here are nine of the most used VA forms with quick tips on how, when, and why to use them.

VA Form 10182

Decision Review Request: Board Appeal (Notice of Disagreement)

VA form 10182 is used by veterans who want the Board of Veterans’ Appeals to review the VA’s decision on their claim. If you disagree with the results of your VA benefits claim or supplemental or higher-level review decision, you can request a review of that decision by the Board.

You can get a copy of VA form 10182 online, pick one up at your regional VA office, or call the VA to request one at 800-827-1000.

In general, Form 10182 must be submitted within 1 year of the date of the VA mailed your decision notice. The only exception is if you are disputing who should receive the benefits. If you and another person disagree over who should receive the VA benefits – a “contested claim” – you must submit form 10182 within 60 days of the date the VA mailed your decision notice.

Since you cannot request two appeals consecutively for the same claim, it is important to fill out this form properly the first time.

In Part II of the Decision Review Request form, you’ll need to select which type of review you want from these three options:

  1. Direct Review – A review of the claim as it is, with no additional evidence and no hearing. This is the fastest option (you should obtain a review decision within 1 year).
  1. Evidence Submission – A review of the claim along with additional evidence to support your argument. You have 90 days to submit your new evidence after you submit form 10182.
  1. Board Hearing – A review of the claim along with additional evidence (if you want but not required) and a chance to speak with the Judge about your disagreement (either in person or virtually).

In Part III, you need to list the issues in the VA decision that you disagree with, along with the date of that decision. You can list just one or several issues. For example, you may disagree with your effective date, service connection, or disability evaluation. List it and add the date of that decision.

Note that while you don’t have to appeal every single issue you list to the Board, you cannot add an issue later. Only the issues listed on form 10182 will be considered in your appeal.

Finally, you need to sign and submit form 10182. There are three ways to submit your form:

  1. Mail the completed form to the Board of Veterans’ Appeals at PO Box 27063, Washington, D.C. 20038, or
  2. Take the completed form to your VA regional office in person, or
  3. Fax the completed form to 844-678-8979.

If you need help filling out VA Form 10182 or preparing evidence for a decision review, our veterans’ disability attorneys can assist you.

VA Form 20-0995

Decision Review Request: Supplemental Claim

VA form 20-0995 is used by veterans who disagree with the VA’s decision on their claim and want to file a “supplemental claim” that adds new evidence to support their claim. When you submit a supplemental claim, the VA will review the new evidence and decide whether it changes their decision.

You can get a copy of VA form 20-0995 online, pick one up at your regional VA office, or call the VA at 800-827-1000 to request a form.

In general, Form 20-0995 can be submitted at any time. There is no deadline. However, if you want to preserve your original effective date (and thereby maximize any potential back pay), you must file it within 1 year of the date the VA mailed its decision. Supplemental claims can be submitted for any type of claim except fiduciary claims and contested claims.

In Part II of the Supplemental Claim form, you’ll need to list each issue in your VA decision that you want to have reviewed in your supplemental claim. The easiest way to do this is to look at your decision notices, read the list of adjudicated issues, and select the issues you want to be reviewed AND have additional evidence for. Then list the date of the decision notice for each issue.

In Part III, you need to gather your new and relevant evidence.

  1. If you have this evidence with you, write your name and file number on each page and attach it to form 20-0995.
  2. If you want VA to gather any non-federal records for you (like non-VA medical records or other private provider records), you will need to print, fill out, and attach the proper authorization forms to form 20-0995. The authorization forms you’ll need should be listed on your decision letter.
  3. If you want VA to gather any federal records (like VA medical centers, federal agencies, VA treatment facilities), you will need to list the names, locations, and dates of those federal records in Part III of Form 20-0995.

The evidence in your supplemental claim must be both new and relevant. This means (1) the VA did not have this evidence for its prior decision, and (2) the evidence is related to the issue being disputed. For example, if you feel your disability rating should be 70%, not 30%, you will need to provide additional evidence (medical records, physician opinion, or witness statements) that you have not given the VA before and that show your level of difficulty maintaining gainful employment or performing certain daily tasks.

Finally, you need to sign and submit form 20-0995. There are three ways to submit your form:

  1. Mail the completed form to the VA regional office that handles the type of benefit you selected in Part I, line 12, or
  2. Take the completed form to your VA regional office in person, or
  3. Fax the completed form to your VA regional office.

VA aims to deliver a decision on your supplemental claim within 5 months (averaging around 125 days).

If you need help filling out VA form 20-0995 or preparing additional evidence, our veterans’ disability attorneys can assist you.

VA Form 20-0996

Decision Review Request: Higher-Level Review

VA form 20-0996 is used by veterans who want a higher-level review of the VA’s decision on their claim. This “higher-level” review does not incorporate new evidence. It is simply a reevaluation of the evidence you submitted for the previous decision – by a higher-level senior reviewer. If you feel the VA decision was made in error or want a different opinion, you can request a higher-level review.

For disability compensation claims, you can download a copy of VA form 20-0996, use the online application, pick one up at your regional VA office, or call the VA at 800-827-1000 to request a form.

For other types of claims, you can download a copy of VA form 20-0996, or pick one up at your regional VA office.

In general, Form 20-0996 must be submitted within 1 year of the date the VA decision notice. Anyone can request a higher-level review, except those who have already had a higher-level review or Board appeal on that same claim and those who are disputing who should receive the benefits (contested claims).

In part II of form 20-0996, you will need to select your benefit type. Your benefit type will be listed on the VA decision notice. You must complete a separate 20-0996 form for each benefit type.

While you cannot submit new evidence in Form 20-0996, you CAN request a conference with the higher-level reviewer to discuss your concerns over the phone. To request an informal review, fill out part IV of the printed form (part III of the online application).

You only get one informal conference, so be sure to be prepared and schedule enough time to voice your concerns during this call. You may want to have your veteran’s representative or advocate with you during this call. VA points out that providing a written statement of the errors and issues with form 20-0996 may produce faster results than scheduling an informal conference.

In part VI of form 20-0996, you will need to list each issue from your decision notice that you want to have examined in the higher-level review. For each issue, list the date of the decision notice (the most recent one). Remember to only list the issues related to the benefit type you selected in Part III. If you want a higher-level review of issues related to another benefit type, you’ll need to fill out a separate form 20-0996 for that benefit type.

Finally, you need to sign and submit form 20-0996. There are three ways to submit your form:

  1. Mail the completed form to the VA regional office that handles the type of benefit you selected on the form, or
  2. Take the completed form to your VA regional office in person, or
  3. Fax the completed form to your VA regional office.

VA aims to deliver a decision on your higher-level review within 5 months (averaging around 125 days).

If you need help filling out VA form 20-0996 or preparing evidence for a decision review, our veterans’ disability attorneys can assist you.

VA Form 21-0781

Statement in Support of Claim for Service Connection for PTSD

VA form 21-0781 is used by veterans who have been diagnosed with posttraumatic stress disorder (PTSD) and are seeking PTSD benefits or services.

You can get a copy of VA form 21-0781 online, pick one up at your regional VA office, or call the VA to request one at 800-827-1000.

To obtain service connection for PTSD, you will need to have evidence showing:

  1. Diagnosis with PTSD
  2. A traumatic in-service event
  3. The traumatic in-service event caused your PTSD diagnosis

In part II of form 21-0781, you will need to list the stressful events that you feel caused your PTSD diagnosis. For each event, describe:

  • What happened
  • Your unit assignment
  • Date of the event
  • Location of the event
  • Your dates of assignment
  • Full names and unit assignments of anyone killed or injured during the event
  • Any medals you received due to the event

The dates should be as specific as possible but can fall in a 60-day range. If you don’t know the exact date, try to remember what was going on around the time of the event (holidays, news headlines, weather conditions) and use that to narrow your date. We once had a case involving a veteran who claimed he was at the DMZ in Korea and exposed to Agent Orange. He could not remember the exact date, but he remembered being there when we landed on the moon. This is an example of linking the events to some major event in the news that happened around the same time as the stressor event.

While you may not remember the names and unit assignments of fallen comrades, write as much as you can recall. Try not to leave any part of the form blank. The more information, the better.

For veterans who obtained a medal or award like a Combat Action Award or Purple Heart, proving service-connection for diagnosed PTSD is relatively straightforward. However, if the exact stressful event that caused your PTSD is harder to pinpoint, or if your military discharge documents do not show active combat, it can be very challenging to prove service-connection. In this case, your list of stressful incidents must be very detailed.

Typically, the VA will reject PTSD service connection because the veteran could not verify a specific stressor or is not officially diagnosed with PTSD. But there is a wide array of evidence you can use to pinpoint the date and location of a specific stressor.

For example, if your military records show sudden behavioral changes or disciplinary measures that were once out of character, you can use these records to help determine which stressor may have been likely to trigger the development of PTSD.

You can also submit a buddy letter testifying to any traumatic events that are not documented in military records. The statements included in the buddy letter may be able to be verified through other means of investigation.

Finally, you need to sign and submit form 21-0781. There are three ways to submit your form:

  1. Mail the completed form to the VA regional office,
  2. Take the completed form to your VA regional office in person, or
  3. Fax the completed form to your VA regional office.

If you need help filling out VA form 21-0781 or gathering evidence of PTSD service connection, our veterans’ disability attorneys can assist you.

VA Form 21-0781a

Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault

VA Form 21-0781a is used by veterans who have been diagnosed with PTSD resulting from personal assault (physical attacks, military sexual trauma) and who are seeking PTSD benefits or services. Veterans with PTSD caused by all other forms of trauma should fill out a different form (VA Form 21-0781).

You can get a copy of VA form 21-0781a online, pick one up at your regional VA office, or call the VA to request one at 800-827-1000.

Incidents of personal assault can be more difficult to prove, especially when the personal assault was not reported during service or the service member received no immediate treatment for the incident. In form 21-0781a, be as specific as possible, but if you cannot remember exactly the date or the names of the parties involved, you can provide a vaguer answer. Never leave a box blank. If you don’t know the exact date, try to remember what was going on around the time of the event (holidays, news headlines, weather conditions) and use that to narrow your date.

In part II, you will need to list the personal assault that you feel contributed to your PTSD diagnosis. For each event, describe:

  • What happened
  • Your unit assignment
  • Date of the event
  • Location of the event
  • Your dates of assignment

In part II, section 9, you will need to provide all sources' names and contact information that can provide evidence that could support your PTSD service connection. Examples of these types of evidence include:

  • Report of the assault to military or non-military authorities
  • Record of contacting a counselor, rape crisis center, or health clinic
  • Journal entry written by you or someone else recording the assault
  • Witness statements from family members, friends, roommates, religious organizations, or military comrades who know about the incident or remember it happening.

In part II, section 10, you will need to provide any other information that may support your claim. Behavioral changes and doctor visits are strong indicators of personal assault and trauma. For example:

  • Medical or dispensary visits without a specific medical condition
  • Sudden financial changes, social changes, or relationship breakups
  • Pregnancy, HIV, or sexually transmitted disease tests
  • Sudden requests for transfer or duty assignment changes
  • Change in alcohol or drug use
  • Sudden weight loss or weight gain
  • Frequent or sudden leave requests
  • Change in over the counter or prescription medication use
  • Disciplinary action, disregard for authority, changes in performance evaluations
  • Sudden depression, anxiety, or panic attacks

Finally, you need to sign and submit form 21-0781a. There are three ways to submit your form:

  1. Mail the completed form to the VA regional office,
  2. Take the completed form to your VA regional office in person, or
  3. Fax the completed form to your VA regional office.

If you need help filling out VA form 21-0781a or gathering evidence of PTSD service connection, our veterans’ disability attorneys can assist you.

VA Form 21-0996

Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

VA Form 21-0966 is used by veterans and surviving family members who are still gathering evidence for their claim but want to secure an early effective date or who want to obtain the most retroactive pay possible. Submitting an intent to file form secures your effective date as the date of your intent to file or the date of your diagnosis, then gives you another 12 months to gather evidence and submit your completed claim.

You can get a copy of VA form 21-0966 online, pick one up at your regional VA office, or call the VA to request one at 800-827-1000.

In Part I of the Intent to File form, be sure to fill out all boxes. Whether you are the claimant, the veteran, or both the claimant AND the veteran, you still need to fill out every line.

In Part II of the Intent to File form, you’ll need to select ALL types of benefits that you want to secure an effective date for compensation, pension, and/or survivors pension and/or dependency and indemnity compensation (DIC) (for surviving family members only).

Note that this intent to file form only secures an effective date for the first completed claim submitted for each benefit type you selected. Later down the line, you would need to submit a new intent to file form if you choose to submit additional claims.

Finally, you need to sign and submit form 21-0966. There are three ways to submit your form:

  1. Mail the completed form to the VA regional office,
  2. Take the completed form to your VA regional office in person, or
  3. Fax the completed form to your VA regional office.

If you need help filling out VA form 21-0966 or preparing a claim for compensation, pension, or DIC benefits, our veterans’ disability attorneys can assist you.

VA Form 21-2680

Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

VA form 21-2680 is used by veterans who want to obtain monthly Housebound payments or Aid and Attendance payments from the VA. If you are eligible for housebound status or require ongoing assistance to perform daily tasks, form 21-2680 will help the VA decide whether you qualify for these benefits.

You can print a copy of VA form 21-2680 online, pick one up at your regional VA office, or call the VA to request one at 800-827-1000.

A veteran can only receive either Housebound benefits or Aid and Attendance benefits – not both.

To be eligible for VA housebound benefits, a veteran must have a permanent disability that renders them homebound (spending a majority of their time at home) AND receive a VA pension. Typically, a veteran with housebound status will meet at least one of the following:

  • Have a permanent disability rated as 100% disabling, or
  • Have a permanent disability rated as 100% disabling and at least one other disability rated as 60% or more disabling

To be eligible for VA aid and attendance benefits, a veteran or survivor must receive a VA pension, AND at least one of the following must be true:

  • Veteran needs someone to help you perform daily tasks (like feeding, bathing, dressing) or,
  • Veteran spends much of each day in bed due to service-connected disability or illness, or
  • Veteran is a nursing home patient due to physical or mental disability related to a service-connected disorder, or
  • Veteran has limited eyesight that cannot be improved with corrective lenses to at least 5/200 vision in both eyes or a visual field of at least 5 degrees.

To complete VA form 21-2680, fill out section I and section II completely.

In section II, you will need to select the benefit you are applying for – either special monthly compensation (SMC) or special monthly pension (SMP). Select only one benefit type.

SMC benefits are for veterans and surviving family who are eligible for VA compensation due to a service-related disability or death and require either (1) an aid and attendant to help perform daily tasks (bathing, dressing, feeding, bathroom, prosthetic assistance), or (2) are housebound (largely confined to the home due to a permanent service-connected disability).

SMP benefits are for veterans and surviving family who are eligible for VA pension and/or survivors benefits and require either (1) an aid and attendant to help perform daily tasks (bathing, dressing, feeding, bathroom, prosthetic assistance), or (2) are housebound (largely confined to the home due to a permanent service-connected disability).

Section III and Section IV must be completed by a medical professional who will conduct an exam and record evidence of physical or mental impairment in relation to the homebound status or aid and assistance needs of a veteran due to their service-connected condition.

You may want to include other forms of helpful evidence with VA form 21-2680, like evidence documenting your daily routine, your transportation methods, or a doctor’s opinion regarding your need for aid and attendance or your housebound care needs.

Those seeking aid and attendance for nursing home patients should also complete a Request for Nursing Home Information in Connection with Claim for Aid and Attendance (VA Form 21-0779).

Finally, you need to submit the completed VA form 21-2680. There are two ways to submit your form:

  1. Mail the completed form to the pension management center (PMC) in your state, or
  2. Take the completed form to your VA regional office in person.

If you need help filling out VA form 21-2680 or preparing evidence to support your claim for homebound status or aid and attendance, our veterans’ disability attorneys can assist you.

VA Form 21-4138

Statement in Support of Claim

VA Form 21-4138 (sometimes called VA form 214138) is used by veterans who want to submit their own statement, a witness statement, a VA buddy statement, or testimony from someone whose knowledge of the veteran could help support a claim for VA benefits.

You can print a copy of VA form 21-4138, fill out form 21-2680 online, pick one up at your regional VA office, or call the VA to request one at 800-827-1000.

Fill out Section I completely and accurately.

In Section II, you are free to write any information that you feel would help support your claim for service connection and/or VA benefits.

Examples of information you may want to include in Section II include: Statement from family members, friends, or other veterans who were direct witnesses of any physical or behavioral changes, plus the dates of the observed changes.

Examples of supporting statements include statements describing a sudden increase or change in:

  • Alcohol or drug use
  • Anxiety or paranoia
  • Confusion or memory loss
  • Depression or isolation
  • Difficulty breathing
  • Financial changes
  • Insomnia, sleep apnea, or nightmares
  • Irritability or anger
  • Medical visits without a specific cause
  • Mobility problems
  • Over the counter medication use
  • Pain complaints
  • Relationship breakups
  • Weight loss or weight gain

In writing the statement, consider the goal. Are you seeking a higher disability rating? Or service connection for PTSD? Or both? Be sure that the statement is relevant - and support those specific claims.

For example, in service connection claims, you will want to include specific information about the date, location, and events that caused your disability, and any secondary conditions your disability has caused, as best as you can remember. Details are best, but vague information is much better than no information.

For higher disability rating requests, you will need to include specific information on your symptoms over time, including dates as close as you can remember. How your symptoms have worsened, how your treatment has changed with time, and how your condition has affected your ability to perform work, social interaction, and daily routine tasks over time.

You can either provide statements to support one specific claim, or all claims you have submitted to VA. Either way, try to organize your statement in relation to each claim. For example, write about any worsening physical symptoms of your medical condition. Then you can switch to writing about any worsening mental symptoms of your medical condition.

Finally, you need to sign VA form 21-4138 and mail the completed form to the Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

If you need help filling out VA form 21-4138 or preparing a compelling statement to support your VA claim, our veterans’ disability attorneys can assist you.

VA Form 21-4192

Request for Employment Information in Connection with Claim for Disability Benefits

VA form 21-4192 is used by veterans who want to apply for Total Disability Rating Based on Individual Unemployability (TDIU) benefits. As part of the application to obtain individual unemployability disability benefits, the veteran’s most recent employer must fill out and submit VA form 21-4192.

In most cases, once the veteran sends in an application for TDIU benefits, the VA will send form 21-4192 to the employers listed on the TDIU benefits application. In other cases, VA will send the veteran a copy of VA form 21-4192. You can also get a copy of VA form 21-4192 online, pick one up at your regional VA office, or call the VA to request one at 800-827-1000.

If you intend to take form 21-4192 to your former employer yourself, enter the name and address of your most recent employer in box 1. In box 2, enter the address of the VA Evidence Intake Center: Department of Veterans Affairs Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.

Next, complete Section I, then deliver the form to your most recent employer and tell them to fill out sections II, III, and IV. They will then need to mail the form to the VA Evidence Intake Center at the address you listed in box 2 (see above).

If an employer is unavailable to fill out the form, the veteran should let VA know. VA Form 21-4192 is not required to obtain TDIU benefits.

If VA has not received a completed form 21-4192 from the former employer within 15-30 days of sending it out, VA will contact the employer or let the veteran know that they need to take action to obtain the completed form.

If you need help filling out VA form 21-4192 or preparing a claim for TDIU benefits, our veterans’ disability attorneys can assist you.

Share



You might also like: