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
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
Register notices described above for further details.
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.