Fill - Free fillable VA10182 VA FORM 10182, DECISION REVIEW REQUEST: BOARD APPEAL PDF form

OMB Approved No. 2900-0674

Respondent Burden: 30 Minutes

Expiration Date: Feb. 28, 2022

DECISION REVIEW REQUEST: BOARD APPEAL

(NOTICE OF DISAGREEMENT)

PART I - PERSONAL INFORMATION

1. VETERAN'S NAME (First, middle initial, last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VETERAN'S VA FILE NUMBER (if different than their SSN)

C/CSS -

4. VETERAN'S DATE OF BIRTH

5. IF I AM NOT THE VETERAN, MY NAME IS (First, middle initial, last)

6. MY DATE OF BIRTH (If I am not the Veteran)

7. MY PREFERRED MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

I AM HOMELESS

8. MY PREFERRED TELEPHONE

NUMBER (Include Area Code)

9. MY PREFERRED E-MAIL ADDRESS 10. MY REPRESENTATIVE'S NAME

PART II - BOARD REVIEW OPTION (Check only one)

11. A Veterans Law Judge will consider your appeal in the order in which it is received, depending on which of the following review options you select.

(For additional explanation of your options, please see the attached information and instructions.)

11A. Direct Review by a Veterans Law Judge: I do not want a Board hearing, and will not submit any additional evidence in support of my appeal.

(Choosing this option often results in the Board issuing its decision most quickly.)

11B. Evidence Submission Reviewed by a Veterans Law Judge: I have additional evidence in support of my appeal that I will provide within the

next 90 days, but I do not want a Board hearing. (Choosing this option may add delay to issuance of a Board decision.)

11C. Hearing with a Veterans Law Judge: I want a Board hearing and the opportunity to submit additional evidence in support of my appeal that I

will provide within 90 days after my hearing. (Choosing this option may add delay to issuance of a Board decision.)

PART III - SPECIFIC ISSUE(S) TO BE APPEALED TO A VETERANS LAW JUDGE AT THE BOARD

12. Please list each issue decided by VA that you would like to appeal. Please refer to your decision notice(s) for a list of adjudicated issues. For each

issue, please identify the date of VA's decision and the area of disagreement.

Check here if you attached additional sheets. Include the Veteran's last name and last 4-digits of the Social Security number.

Check the SOC/SSOC Opt in box if any issue listed below is being withdrawn from the legacy appeals process.

Opt In from SOC/SSOC

A. Specific Issue(s) B. Date of Decision

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.

13. SIGNATURE (Appellant or appointed representative) (Ink signature)

14. DATE SIGNED

VA FORM

FEB 2019

10182

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.

INFORMATION AND DETAILED INSTRUCTIONS FOR COMPLETING

DECISION REVIEW REQUEST: BOARD APPEAL

(NOTICE OF DISAGREEMENT)

NOTE: Use this form ONLY if you received your VA decision on or after February 19, 2019, and you wish to appeal one or more issues to a Veterans

Law Judge at the Board of Veterans' Appeals. DO NOT USE THIS FORM to submit a Supplemental Claim (if you wish to have additional evidence

reviewed by a VA rater) or request a Higher-Level Review (if you wish to have a new decision by a VA senior reviewer).

If you have any questions about the filing deadline in your case, ask your representative or your local VA office. Filing on time is very important.

Failing to submit on time could result in you losing your right to appeal.

When should I fill out a Notice of Disagreement? If you have received a decision from a local VA office or a higher-level adjudicator with which you

disagree, and you would like one or more issues to be decided by a Veterans Law Judge, you must fill out and submit a Notice of Disagreement. You

can choose to appeal all or only some of the issues previously decided, however, ONLY those issues that you list on your Notice of Disagreement will be

considered on appeal.

How long do I have to submit my Notice of Disagreement? Your completed Notice of Disagreement must be post-marked or received by the Board

within one year (365 days) from the day that your local VA office mailed the notice of the decision. If you do not provide all the information requested in

the Notice of Disagreement, VA will consider your form incomplete and will contact you to request clarification and explain your options.

Contested Claim: If you are one of multiple people claiming the right to the same benefit, your completed Notice of Disagreement must be post-marked

or received by the Board within 60 days from the day that your local VA office mailed the notice of the decision. VA will notify you and provide additional

information if you are a party to a contested claim.

What are my options for the Board's review? You must choose one of three options for how a Veterans Law Judge will review the issue(s) on appeal.

Determine which of the below options best fits your situation. Please note that you may choose only one option for each issue you wish to appeal.

REVIEW OPTION DESCRIPTION

Direct Review - Choose this option if you do not want to submit additional evidence, and you do not want a hearing with a

Veterans Law Judge.

- The Veterans Law Judge and Board team will review the issue(s) you appealed, and make a new determination based

on the evidence that the local VA office considered.

- Choosing this option will often result in a Veterans Law Judge at the Board being able to issue its decision most

quickly.

Evidence Submission - Choose this option if you want to submit additional evidence, but you do not want to have a hearing with a

Veterans Law Judge.

- After 90 days, any additional evidence added to your claim will not be considered by the Board.

- The Veterans Law Judge and Board team will review the issue(s) you appealed, considering the evidence that the

local VA office considered, along with any additional evidence that you submit within 90 days after VA's receipt of

your Notice of Disagreement.

Hearing Request - Please note that a Board hearing is optional, and may increase the wait time for a Board decision.

- Choose this option if you want a hearing with a Veterans Law Judge, which includes the option to

submit additional evidence.

- The Board will contact you to schedule your hearing and provide additional information.

- After your hearing, the Veterans Law Judge and Board team will review the issue(s) you appealed, considering the

evidence that the local VA office considered, along with your hearing testimony and any additional evidence that you

submit within 90 days after the hearing.

Find more information on the review options at va.gov/decision-reviews

Where can I get help with filing my appeal? A Veterans Service Organization or a VA-accredited attorney or agent can represent you or provide

guidance. Contact your local VA regional office for assistance or visit: va.gov/ogc/accreditation.asp.

Where do I submit my Notice of Disagreement once I have completed it? When you have completed the Notice of Disagreement, signed and dated

it, you must send it to the Board at the address or FAX number below:

Board of Veterans' Appeals

P.O. Box 27063

Washington, DC 20038

FAX: 844-678-8979

What if I want to modify my Notice of Disagreement? You may make a request to modify your Notice of Disagreement for the purpose of selecting a

different review option in Part II. Any such request must be made by submitting a new Notice of Disagreement form to the Board within one year (365

days) from the date of mailing of the notice of decision on appeal, or within 60 days of the Board's receipt of the Notice of Disagreement, whichever is

later. You cannot request to modify your Notice of Disagreement if you have already submitted evidence to the Board or testified at a hearing with a

Veterans Law Judge.

VA FORM

FEB 2019

10182

OVERVIEW OF NOTICE OF DISAGREEMENT FORM SECTIONS

If you decide to appeal to a Veterans Law Judge at the Board, these instructions will help you complete your Notice of Disagreement.

Part I - PERSONAL INFORMATION Please provide all the personal information in Part I. If desired, you may also enter the claimant's prefix (such as

“Mr.” or “Ms.”) and/or suffix (such as “Jr.” or “Sr.”). If your address has changed recently or will change soon, please notify your local VA office. If you are

homeless, please check the box in item 7. If you wish to include multiple addresses, you may attach additional sheets to the form, explaining how you

would like VA to contact you.

Part II - REVIEW OPTION You must check one, and only one, of the boxes in Part II, Block 11, to choose how you would like the Board to review the

issues identified in Part III. The Board will place your appeal onto a list for consideration in the order it was received. If you wish to request a different

review option for one or more issues listed in Part III, you may attach additional sheets to the form, explaining your preference.

Box 11A - Direct Review by a Veterans Law Judge: Check this box if you do not want to submit additional evidence and you do not want a

Board hearing.

Box 11B - Evidence Submission Reviewed by a Veterans Law Judge: Check this box if you do not want a Board hearing, but you do want

to submit additional evidence with this Notice of Disagreement or within 90 days following VA's receipt of your Notice of Disagreement.

Box 11C - Hearing With a Veterans Law Judge: Check this box if you want a Board hearing with a Veterans Law Judge, which includes the

option to submit additional evidence at your hearing or within 90 days following the hearing.

If you have already submitted a Notice of Disagreement, and wish to change your Board Review Option, please fill out this form completely, indicating

your new choice in Part II.

Part III - SPECIFIC ISSUE(S) BEING APPEALED TO THE BOARD List the issue(s) you would like the Board to review in Block 12A, and the date of

your decision notice in Block 12B. Please refer to your decision notice for a list of adjudicated issues. If you want to appeal more issues, you may attach

additional pages as needed.

Upon receipt of a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC) in the legacy appeals system, you may elect to continue

your appeal either in the legacy appeals system or in the modernized review system. Your decision notice contains further details. If you are filing this

form to opt into the modernized review system for any issues decided in the SOC or SSOC, you must provide notice to VA of your decision to leave the

legacy appeals system for those issues. To do so when using the Notice of Disagreement, please check the box for "OPT IN from SOC/SSOC" in item

12 and list the issue(s) in the SOC or SSOC for which you are seeking review under item 12A as instructed above. Your selection of the BOARD

APPEAL option does not prevent you from changing the review option (in accordance with applicable procedures) before the Veterans Law Judge issues

a decision on the issue(s).

Please note that by checking the "OPT IN from SOC/SSOC" box in item 12 you are acknowledging the following: I elect to participate in the

modernized review system. I am withdrawing all eligible appeal issues listed on this form in their entirety, and any associated hearing requests, from the

legacy appeals system to seek review of those issues in VA's modernized review system. I understand that I cannot return to the legacy appeals system

for the issue(s) withdrawn.

Part IV - CERTIFICATION AND SIGNATURE Please sign and date the Notice of Disagreement, certifying that the statements on the form are true to the

best of your knowledge and belief. An appointed representative may sign on the behalf of the appellant.

WHAT IF I WANT TO ADD ADDITIONAL INFORMATION? If you want to provide any additional information to VA, including why you believe that VA

previously decided one or more issues incorrectly, you may check the box in Block 12 and attach additional sheets to the form. For each issue, please

make sure to identify the date of VA's decision. The Board will not consider any new evidence unless you selected the “Evidence Submission” option in

Part II, Block 11B. The Board will consider argument submitted with any Notice of Disagreement. Please number any additional pages and include the

Veteran's last name and Social Security number (last four digits only).

PRIVACY ACT STATEMENT: Our authority for asking for the information you give to us when you fill out this form is 38 U.S.C. 7105(d)(3), a Federal

statute that sets out the requirement for you to submit a formal appeal to complete your appeal on a VA benefits determination. You use this form to

present your appeal to the Board of Veterans' Appeals (Board). It is used by VA in processing your appeal and it is used by the Board in deciding your

appeal. Providing this information to VA is voluntary, but if you fail to furnish this information VA will close your appeal and you may lose your right to

appeal the benefit determinations you told us you disagreed with. The Privacy Act of 1974 (5 U.S.C. 552a) and VA's confidentiality statute (38 U.S.C.

5701), as implemented by 38 C.F.R. 1.526(a) and 1.576(b), require individuals to provide written consent before documents or information can be

disclosed to third parties not allowed to receive records or information under any other provision of law. However, the law permits VA to disclose the

information you include on this form to people outside of VA in some circumstances. Information about that is given in notices about VA's "systems of

records" that are periodically published in the Federal Register as required by the Privacy Act of 1974. Examples of situations in which the information

included in this form might be released to individuals outside of VA include release to the United States Court of Appeals for Veterans Claims, if you later

appeal the Board's decision in your case to that court; disclosure to a medical expert outside of VA, should VA exercise its statutory authority under 38 U.

S.C. 5109 or 7109, to ask for an expert medical opinion to help decide your case; disclosure to law enforcement personnel and security guards in order

to alert them to the presence of a dangerous person; disclosure to law enforcement agencies should the information indicate that there has been a

violation of law; disclosure to a congressional office in order to answer an inquiry from the congressional office made at your request; and disclosure to

Federal government personnel who have the duty of inspecting VA's records to make sure that they are being properly maintained. See the Federal

RESPONDENT BURDEN: VA may not conduct or sponsor, and the respondent is not required to respond to, this collection of information unless it

displays a valid Office of Management and Budget (OMB) Control Number. The information requested is approved under OMB Control Number

(2900-0674). Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this burden to: VA Clearance

Officer (005R1B), 810 Vermont Ave., NW, Washington, DC 20420. DO NOT send requests for benefits to this address.

VA FORM

FEB 2019

10182

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