INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, OR SURVIVORS PENSION AND/OR DIC

INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, OR SURVIVORS PENSION AND/OR DIC
Before completing this form, read the Privacy Act and Respondent Burden below. This form is used to notify VA of your intent to file for the general benefit(s) checked below.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
Who is filling out this form?

The VeteranA Claimant on Behalf of a Veteran
1. VETERAN'S NAME*

First NameMiddle InitialLast Name
2. VETERAN'S SOCIAL SECURITY NUMBER*
3. HAVE YOU EVER FILED A VA CLAIM?*

YESNO
4. VA FILE NUMBER *
5. VETERAN'S DATE OF BIRTH (MM,DD,YYYY)*

MonthDayYear
6. VETERAN'S SERVICE NUMBER (If applicable)
7. MAILING ADDRESS
No. & Street
Apt/Unit Number
City
State/Province
Country
ZIP Code
Please enter a valid ZIP code in the format ##### or #####-####.
8. TELEPHONE NUMBER (Include Area Code)
Enter international Phone Number (if applicable)
I agree

to receive electronic correspondence from VA in regards to my claim.
9. EMAIL ADDRESS (If applicable)
example@example.com
SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION

Complete this section ONLY if the claimant is NOT the veteran.
10. CLAIMANT'S NAME*

First NameMiddle InitialLast Name
11. CLAIMANT'S SOCIAL SECURITY NUMBER*
12. HAVE YOU EVER FILED A VA CLAIM?*

YESNO
13. VA FILE NUMBER (If applicable)
14. RELATIONSHIP TO VETERAN

SPOUSECHILDFIDUCIARYVETERAN SERVICE OFFICERALTERNATE SIGNERTHIRD-PARTYOther
15. CLAIMANT'S DATE OF BIRTH (MM,DD,YYYY)*

MonthDayYear
16. MAILING ADDRESS
No. & Street
Apt/Unit Number
City
State/Province
Country
ZIP Code
Please enter a valid ZIP code in the format ##### or #####-####.
17. TELEPHONE NUMBER (Include Area Code)
Enter international Phone Number (if applicable)
I agree

to receive electronic correspondence from VA in regards to my claim.
18. EMAIL ADDRESS (If applicable)
example@example.com
SECTION III: 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.
19. I intend to file for the general benefit(s) checked below: (Choose all that apply)

COMPENSATIONPENSIONSURVIVORS 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 at www.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 Il as possible. VA cannot process this form if we cannot identify the claimant and veteran.
SECTION IV: DECLARATION OF INTENT AND SIGNATURE
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.
20. SIGNATURE OF VETERAN/CLAIMANT/AUTHORIZED AGENT*

Clear
21. Date Signed*

MonthDayYear
22. 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.
PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, orfor fraudulent receipt of any document you are not entitled to.

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 Veteran Readiness 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 the intent of the claimant 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 5 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

SUPERSEDES VA FORM 21-0966, AUG 2018.
Should be Empty:

INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION, OR SURVIVORS PENSION AND/OR DIC

SECTION I: VETERAN'S IDENTIFICATION INFORMATION

7. MAILING ADDRESS

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION

16. MAILING ADDRESS

SECTION III: GENERAL BENEFIT ELECTION

SECTION IV: DECLARATION OF INTENT AND SIGNATURE