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.
No. &
Street
SECTION III: DECLARATION OF INTENT
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to expedite processing of the form.
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)
SECTION I: CLAIMANT/VETERAN IDENTIFICATION
VA FORM
AUG 2018
21-0966
7. VETERAN'S SEX
FEMALE
4. VETERAN'S DATE OF BIRTH (MM,DD,YYYY)
MALE
2. CLAIMANT'S SOCIAL SECURITY NUMBER
OMB Control No. 2900-0826
Respondent Burden: 15 minutes
Expiration Date: 08/31/2021
NOTE: Please read the Privacy Act and Respondent Burden below before completing the form.
3. VA FILE NUMBER (If applicable)
9. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
SECTION II: GENERAL BENEFIT ELECTION
6. VETERAN'S SOCIAL SECURITY NUMBER
5. VETERAN'S NAME (First, Middle Initial, Last) (If different from claimant)
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
1. CLAIMANT'S NAME (First, Middle Initial, Last)
YearDayMonth
EXISTING STOCK OF VA FORM 21-0966, MAR 2017,
WILL BE USED.
Apt./Unit Number
City
ZIP Code/Postal Code
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.
PENSION
13. I intend to file for the general benefit(s) checked below: (Choose all that apply)
COMPENSATION
SURVIVORS PENSION AND/OR DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
NOTE: Only check the box below if you are a surviving dependent of the veteran.
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.
11.TELEPHONE NUMBER (Include Area Code)
12. EMAIL ADDRESS (If applicable)
14B. DATE SIGNED (MM,DD,YYYY)
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.)
14A. SIGNATURE OF CLAIMANT/AUTHORIZED REPRESENTATIVE
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.
8. VETERAN'S SERVICE NUMBER (If applicable)
10. HAS THE VETERAN EVER FILED A
CLAIM WITH VA?
YES NO
State/Province
Country
click to sign
signature
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