Form Approved: OMB No. 2900-0674
Expiration Date: Feb. 28, 2022
Respondent Burden: 1 Hour
IMPORTANT: Read the attached instructions before you fill out this form. VA also encourages you to get assistance from your
representative in filling out this form.
1. NAME OF VETERAN (Last Name, First Name, Middle Initial)
4. I AM THE:
OTHER (Specify)
A. HOME (Include Area Code)
B. WORK (Include Area Code)
(Number & Street or Post Office Box, City, State & ZIP Code)
(Last Name, First Name, Middle Initial)
8. THESE ARE THE ISSUES I WANT TO APPEAL TO THE BOARD: (Be sure to read the information about this block in paragraph 6 of the attached instructions.)
(List below.)
9. HERE IS WHY I THINK THAT VA DECIDED MY CASE INCORRECTLY: (Be sure to read the information about this block in paragraph 6 of the attached instructions.)
(Continue on the back, or attach sheets of paper, if you need more space.)
IMPORTANT: Read the information about this block in paragraph 6 of the attached instructions. This block is used to request an optional Board of Veterans'
Check one (and only one) of the following boxes:
I DO NOT WANT AN OPTIONAL BOARD HEARING. (Choosing this option often results in the Board issuing its decision most quickly. If you choose, you may write
down what you would say at a hearing and submit it directly to the Board.)
BY LIVE VIDEOCONFERENCE AT A LOCAL VA OFFICE. (Choosing this option will add delay to issuance of a Board decision.)
IN WASHINGTON, DC. (Choosing this option will add delay to issuance of a Board decision.)
AT A LOCAL VA OFFICE.* (Choosing this option will add significant delay to issuance of a Board decision.)
This option is not available at the Washington, DC, or Baltimore, MD, Regional Offices.
(Ink signature required)
12. DATE
(Not required if signed by appellant. See paragraph 6 of the
instructions.) (Ink signature)
14. DATE
FEB 2019
(Attach additional sheets, if necessary)
We are required by law to give you the information in this box. Instructions for filling out the form follow the box.
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 (2900-0085). Public reporting burden for this collection of information is estimated to
average one hour 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.
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 file 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.
1. CONSIDER GETTING ASSISTANCE: We have tried to give you the general information most people need to complete this
form in these instructions, but the law about veterans' benefits can be complicated. If you have a representative, we encourage you to
work with your representative in completing this form. If you do not have a representative, we urge you to consider getting one.
Most people who appeal to the Board of Veterans' Appeals (Board) do get a representative. Veterans Service Organizations (VSOs)
will represent you at no charge and most people (more than 80 percent) are represented by VSOs. You can find a listing of VSOs on
the Internet at:
. Under certain circumstances, you may pay a lawyer or "agent" to represent you. Your local
VA office can further assist you with questions regarding how to appoint a VSO, attorney, or agent to represent you. You can reach
your local VA office toll-free at 1-800-827-1000. Your local bar association may be able to provide you with the names of attorneys
who specialize in veterans' law.
2. WHAT IS THIS FORM FOR? You told your local VA office that you disagreed with some decision it made on your claim for
VA benefits, called filing a "Notice of Disagreement." That office then mailed you a "Statement of the Case" (SOC) that told you
why and how it came to the decision that it did. After you have read the SOC, you must decide if you want to go ahead and complete
your appeal so that the Board will review your case. If you do, you or your representative must fill out this form and file it with VA.
"Filing" means delivering the completed form to VA in person or by mailing it based on the instructions you received with your
SOC. Paragraph 4 tells you how much time you have to file this form and paragraph 7 tells you where you file it.
When we refer to "your local VA office" in these instructions, we mean the VA Regional Office that sent you the SOC or, if you
have moved out of the area served by that office, the VA Regional Office that now has your VA records.
3. DO I HAVE TO FILL OUT THIS FORM AND FILE IT? Fill out this form and file it with VA if you want to complete your
appeal. If you do not, VA will close your appeal without sending it to the Board for a decision. If you decide that you no longer
want to appeal after you have read the SOC, you don't have to do anything.
4. HOW LONG DO I HAVE TO COMPLETE THIS FORM AND FILE IT? Under current law, there are three different ways
to calculate how much time you have to complete and file this form. The one that applies to you is the one that gives you the most
(a) You have one year from the day your local VA office mailed you the notice of the decision you are appealing.
(b) You have 60 days from the day that your local VA office mailed you the SOC.
(c) Your local VA office may have sent you an update to the SOC, called a "Supplemental Statement of the Case" (SSOC).
If that SSOC was provided to you in response to evidence you or your representative submitted within the one-year period
described in paragraph 4(a) of these instructions, above, and if you have not already filed this form, then you have at least 60
days from the time your local VA office mailed you the SSOC to file it even though the one-year period has already expired.
See 38 C.F.R. 20.302(b)(2).
There is one special kind of case, called a "simultaneously contested claim," where you have 30 days to file this form instead of the
longer time periods described above. A "simultaneously contested claim" is a case where two different people are asking for the
same kind of VA benefit and one will either lose, or get less, if the other wins. If you are not sure whether this special exception
applies, ask your representative or call your local VA office.
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 file on time could result in you losing your right to appeal.
5. WHAT IF I NEED MORE TIME? If you need more time to complete this form and file it, write to the address included on
your SOC, explaining why you need more time. You must file your request for more time before the normal time for filing this form
runs out. If you file by mail, VA will use the postmark date to decide whether you filed the form, or the request for more time to file
it, on time.
is easy to understand, please refer to the sections below for additional information regarding each block.
Block 3. If your appeal involves an insurance claim or some issue related to a VA home loan, enter your VA insurance or
VA loan number here. For most kinds of cases, you will leave this block blank.
Blocks 4-7. These blocks are for information about the person who is filing this appeal. If you are a representative filling
out this form for the person filing the appeal, fill in the information about that person, not yourself. Block 7 can be left
blank if the person filing the appeal is the Veteran.
Block 8. This is the block where you tell us exactly what you are appealing. You do this by identifying the "issues" you are
appealing. Your local VA office has tried to accurately identify the issues and has listed them on the SOC and any SSOC it
sent you. Save what you want to tell us about why you are appealing for the next block (Block 9).
Check the first check box in Block 8 if you only want to continue your appeal on some of the issues listed on the SOC and
any SSOC you received. List the specific issues you want to appeal in the space under the first box. While you should not
use this form to file a new claim or to appeal new issues for the first time, you can also use this space to call the Board's
attention to issues, if any, you told your local VA office in your Notice of Disagreement you wanted to appeal that are not
included in the SOC or any SSOC. If you want to file a new claim, or appeal new issues (file a new Notice of
Disagreement), do that in separate correspondence. Do not check the second box if you check this box.
If you think that your local VA office has correctly identified the issues you are appealing and, after reading the SOC and
any SSOC you received, you still want to appeal its decisions on all those issues, check the second box in Block 8. Do not
check the first box if you check this box.
Block 9. Use this block to tell us why you disagree with the decision made by your local VA office. Tie your arguments to
the issues you identified in Block 8. Tell us what facts you think VA got wrong and/or how you think VA misapplied the
law in your case. Try to be specific. If you are appealing a rating percentage your local VA office assigned for one or more
of your service-connected disabilities, tell us for each service-connected disability rating you have appealed what rating
would satisfy your appeal (The SOC, or SSOC, includes information about what disability percentages can be assigned for
each disability under VA's "Rating Schedule.") You may want to refer to the specific items of evidence that you feel
support your appeal, but you do not have to describe all of the evidence you have submitted. The Board will have your
complete file when it considers your case. You should not attach copies of evidence you have already sent to VA.
In completing this block, please also let us know if there is any additional evidence that you feel needs to be obtained to
support your appeal. You may either submit this evidence along with this response, or at a minimum notify VA of its
existence so that the evidence can be obtained on your behalf.
If you need more space to complete Block 9, you can continue it on the back of the form and/or you can attach sheets of
paper to the form. If you want to complete this part of the form using a computer word-processor, you may do so. Just
attach the sheets from your printer to the form and write "see attachment" in Block 9.
Block 10. It is very important for you to check one, and only one, of the boxes in Block 10. This lets us know whether or
not you want to appear at a Board hearing and, if so, where you want to appear. Please keep in mind that a Board hearing
is entirely optional, and it is not necessary for you to have a hearing for the Board to decide your appeal. Hearings
often increase wait time for a Board decision. If you do not check any of the boxes, the Board will assume that you DO
NOT want a Board hearing and your case will be decided taking into consideration the arguments already made, including
your explanation on this form as to why you think VA decided your case incorrectly.
If you ask for a Board hearing, you and your representative (if you have one) can tell us why you think the Board should act
favorably on your appeal (present argument). You can also tell us about the facts behind your claim and you can bring
others (witnesses) to the hearing who have information to give the Board about your case. At your option, you can submit
more evidence at a Board hearing. If you do ask for a Board hearing, it can be very helpful to have a representative assist
you at the hearing. Please note that VA cannot pay any expenses that you (or your representative or witnesses) incur in
connection with attending any Board hearing.
The purpose of a hearing is to receive argument and testimony relevant and material to the issue or issues in your case that
are on appeal. Hearings conducted by the Board are nonadversarial in nature. Parties to a hearing are permitted to ask
questions, including follow-up questions, but cross-examination is not allowed. While the types of questions that may be
asked are not limited by the legal rules of evidence that typically apply in an adversarial trial setting, reasonable bounds of
relevancy and materiality still must be maintained.
Here is specific information about each of the check boxes in Block 10:
Box A: Check Box A if you decide that you do not want a Board hearing. It is not necessary for you to have a hearing for the
Board to decide your appeal, and this is often the fastest option to issuance of a Board decision. If you feel that you have
already sent VA everything that the Board will need to decide your case, including making all desired arguments in support of
your appeal, then there is no need for a hearing to be held. In addition, a hearing is not needed if the only thing you would
like to do is submit additional evidence in support of your appeal. Instead, you may submit such additional evidence, or at a
minimum notify VA of its existence and request that it be obtained, without a hearing being held. If you choose, you may
also write down what you would say at a hearing and submit it directly to the Board. If you check this box, do not check any
of the other boxes in Block 10.
Box B: Check Box B if you want to appear at a live Board videoconference hearing. This option allows you to have a hearing
by way of videoconferencing where you will be at the local VA office and the Veterans Law Judge hearing your case will be
at the Board's offices in Washington, DC. Videoconferencing allows the Veterans Law Judge holding the hearing to see and
hear you, your representative, and witnesses (if any). You will also be able to see and hear the Veterans Law Judge. Please
note that choosing a live videoconference hearing will delay issuance of a Board decision in your appeal due to scheduling
demands. This type of hearing, however, can often be scheduled more quickly than a Board hearing where all participants
(including the Veterans Law Judge) are physically present together at the local VA office.
Box C: Check Box C if you want to appear for a hearing at the Board's offices in Washington, DC. Having your Board
hearing by live videoconference (Box B) is usually less expensive for you, because you will not incur expenses associated
with travel to Washington, DC. Please note that choosing a Board hearing in Washington, DC, will delay issuance of a
Board decision in your appeal due to scheduling demands.
Box D: Check Box D if you want a Board hearing at your local VA office. If you select this option, both you and the
Veterans Law Judge assigned to hear your case will be physically present together at the local VA office. Please note that
this option will significantly delay issuance of a Board decision in your appeal due to travel requirements and scheduling
demands for Board personnel. You can check with your local VA office for an estimate of how long it may take before your
case could be scheduled for a Board hearing at that local VA office.
Blocks 11 and 12. This form can be signed and filed by either the person appealing the local VA decision, or by his or her
representative. Sign the form in Block 11 if you are the person appealing, or if you are a guardian or other properly appointed
fiduciary filing this appeal for someone else. In cases where an incompetent person has no fiduciary, or the fiduciary has not
acted, that person's "next friend," such as a family member, can sign and file this form. If the representative is filing this form,
Block 11 can be left blank. Regardless of who signs the form, we encourage you to have your representative check it over
before it is filed. Place the date you sign in Block 12.
Blocks 13 and 14. If you are a representative filing this form for the appellant, sign in Block 13. Otherwise, leave Block 13
blank. If you are an accredited representative of a VSO, also insert the name of the VSO in Block 13. Note that signing this
form will not serve to appoint you as the appellant's representative. Contact your local VA office if you need information on
appointment. Place the date you sign in Block 14.
7. WHERE DO I FILE THE FORM ONCE I HAVE COMPLETED IT? When you have completed the form, signed and dated
it, follow the instructions you received with your SOC of where to send the form.
8. OTHER SOURCES OF INFORMATION: You can find a “plain language” pamphlet that describes the VA appeals process
called “How Do I Appeal” on the Internet at:
. You can also find the formal rules for
the VA appeals process in title 38, Code of Federal Regulations, Part 20. A complete copy of the Code of Federal Regulations is
available on the Internet at: A printed copy of the Code of Federal Regulations may also
be available at your local law library. More general information about VA benefit programs and eligibility can be found on the
Internet at:
9. SPECIAL NOTE FOR ATTORNEYS AND VA ACCREDITED AGENTS. There are statutory and regulatory restrictions on
the payment of your fees and expenses and requirements for filing copies of your fee agreement with your client with VA.
See 38 U.S.C. 5904 and 38 C.F.R. 14.636-637.
NOTE: Please separate these instructions from the form before you file it with VA. We suggest that you keep these instructions with
your other papers about your appeal for future reference.
HEARINGS BEFORE VA REGIONAL OFFICE PERSONNEL: A hearing before VA regional office personnel, instead of
before a Veterans Law Judge, is not a Board hearing. You can request a hearing before VA regional office personnel by writing
directly to the regional office. DO NOT use this form to request that kind of hearing. If you do, it will delay your appeal. You
should also know that requesting a hearing before VA regional office personnel does not extend the time for filing this form.