COMMENTARY From the NATIONAL SERVICE DIRECTOR JAMES T. MARSZALEK Bookmark your spot L ast March, the Department of Veterans Affairs began requiring that all claims to the agency be filed on standardized VA forms, ending the VA’s longtime practice of informally initiating veterans’ disability claims. This new process has helped the VA make significant progress in reducing its backlog, but more progress can be made with the improved use of one of the most underutilized documents the VA provides: VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC. Though not required to formally start the claims process, an Intent to File allows veterans to informally establish a forthcoming claim. Once the Intent to File is received by the VA, veterans have 12 months to gather evidence and formally file, essentially bookmarking their inten-tions and the effective date for the subsequent formal claim. Submitting the form simply advises the VA of forth-coming actions. Securing an effective date for a benefits claim should be top priority, even before assembling the evidence needed to support the claim. Establishing this official starting point with VA Form 21-0966 ensures veterans will receive the compensation they earned retroactively if their claim is granted, regardless of how long it takes to adjudicate the claim. The form takes roughly 15 minutes to complete, though often less, and OMB Control No. 2900-0826 Respondent Burden: 15 minutes Expiration Date: 7/31/2018 VA DATE STAMP (DO NOT WRITE IN THIS SPACE) INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, OR SURVIVORS PENSION AND/OR DIC (This Form Is Used to Notify VA of Your Intent to File for the General Benefit(s) Checked Below) NOTE : Please read the Privacy Act and Respondent Burden below before completing the form. SECTION I: CLAIMANT/VETERAN IDENTIFICATION NOTE : You can either complete the form online or by hand. Please print your information using blue or black ink, neatly and legibly to help process the form. 1. CLAIMANT'S NAME (First, middle initial, last) 2. CLAIMANT'S SOCIAL SECURITY NUMBER 3. VA FILE NUMBER (If applicable) 4. VETERAN'S DATE OF BIRTH Month Day Year 5. VETERAN'S NAME (First, middle initial, last) (If different from claimant) 6. VETERAN'S SOCIAL SECURITY NUMBER 7. VETERAN'S SEX MALE FEMALE 8. VETERAN'S SERVICE NUMBER (If applicable) 9. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) No. & Street Apt./Unit Number State/Province Country City ZIP Code/Postal Code 11. PREFERRED TELEPHONE NUMBER (Include Area Code) 12. PREFERRED E-MAIL ADDRESS (If applicable) 10. HAS THE VETERAN EVER FILED A CLAIM WITH VA? YES NO SECTION II: GENERAL BENEFIT ELECTION IMPORTANT : VA may not be able to use this form to establish an effective date for benefits if you do not select one or more of the general benefits listed below. 13. I intend to file for the general benefit(s) checked below: (Choose all that apply) COMPENSATION PENSION NOTE: Only check the box below if you are a surviving dependent of the veteran. SURVIVORS PENSION AND/OR DEPENDENCY AND INDEMNITY COMPENSATION (DIC) IMPORTANT : After receiving this form, VA will give you the appropriate application to file for the general benefit you select above. You can also apply for VA disability compensation online through eBenefits at www.ebenefits.va.gov . If you give VA a completed application for the selected general benefit within one year of filing this form, your completed application will be considered filed as of the date of receipt of this form. Only the first completed application for each selected general benefit that is received after you file this form will be considered filed as of the date of receipt of this form. You may indicate your intent to file for more than one general benefit on this form or you may submit a separate intent to file for each general benefit. Please complete as many fields in Section II as possible. VA cannot process this form if we cannot identify the claimant and veteran. SECTION III: DECLARATION OF INTENT By filing this form, I hereby indicate my intent to apply for one or more general benefits under the laws administered by VA. I acknowledge that: (1) this is not a claim for benefits ; (2) I must file a complete application for each general benefit with VA before VA will process my claim; and (3) a complete application for the same general benefit(s) as indicated on this form must be received within one year of the date VA receives this form for my application to be considered filed as of the date of this form. 14A. SIGNATURE OF CLAIMANT/AUTHORIZED REPRESENTATIVE ( Note : Claimant must sign in ink. The claimant's "Authorized Representative" may use a digital signature) 15. NAME OF ATTORNEY, AGENT, OR VETERANS SERVICE ORGANIZATION (Please Print) ( NOTE : This form may only be completed by a Veterans Service Organization, attorney, or agent if a valid power of attorney has been completed.) 14B. DATE SIGNED (MM,DD,YYYY) PRIVACY ACT NOTICE : VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records -VA, published in the Federal Register. Your obligation to respond is required only to preserve a date of claim for an application that is received within one year of receipt of this form. VA uses your Social Security number to identify if you have a claim file and to ensure that your records are properly associated with your claim file. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine the appropriate application and provide it to the claimant. RESPONDENT BURDEN : We need this information to determine and to provide the claimant with the appropriate application for VA benefits (38 U.S.C. 5102). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain . If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM JUL 2015 21-0966 SUPERSEDES VA FORM 21-0966, NOV 2014, WHICH WILL NOT BE USED. VA Form 21-0966 requires information necessary to identify and support compensation, pension and other benefit claims. Additionally, a standardized Notice of Disagreement form (VA Form 21-0958) is required if a claimant wishes to initiate an appeal of a VA decision. These forms can be submitted electronically through eBenefits, over the phone by contacting a DAV national service officer or by mailing a paper copy to a DAV national service office. Learn More Online Contact information for those offices can be found online at DAV.org/find-your-local-office/ and standardized VA forms can be found at dav.org/ veterans/standard-claim-appeal-forms. 16 DAV MAGAZINE NOVEMBER | DECEMBER 2016
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James T. Marszalek
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