VA Form 20-0995 Decision Review Request: Supplemental Claim

INFORMATION AND INSTRUCTIONS FOR COMPLETING DECISION REVIEW REQUEST:
SUPPLEMENTAL CLAIM
IMPORTANT: Please read the information below carefully to help you complete this form quickly and accurately. Some parts of the form also contain
notes or specific instructions for completing that section.

When to Use This Form:
Use this form, VA Form 20-0995, Decision Review Request: Supplemental Claim, to submit a supplemental claim of the decision you received that you
disagree with.
Note: A supplemental claim is a new review of an issue(s) previously decided by the Department of Veterans Affairs (VA) based on
submission of new and relevant evidence. For additional information on the supplemental claim process or other decision review options such as a
higher-level review and appeal to the Board of Veterans' Appeals (BVA), visit www.va.gov/decision-reviews/. This form should only be
used if you DISAGREE with a decision you received.
• If you feel your condition has worsened and is no longer accurately reflected by the level of disability assigned by VA, use
VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, to request an increased evaluation.
You may also submit your claim online, more information is available at www.va.gov/disability.
• If you want to file a request for higher-level review, use VA Form 20-0996, Decision Review Request: Higher-Level Review.
• You can also appeal to the BVA by using VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement).
For additional information on these different options, visit www,va.gov/decision-reviews/.

Where to Submit This Form:
Submit your supplemental claim to one of the addresses shown below that corresponds to your benefit type. It is important that you keep a copy of all
completed forms and materials you give to VA. This form has several key components, which, when filled out completely and accurately, will decrease
the amount of time it takes to process your supplemental claim. This form may only be submitted for review of an issue(s) related to one benefit type
(Compensation, Pension and Survivors Benefits, Fiduciary, Life Insurance, Education, Loan Guaranty (LGY), Veteran Readiness and Employment
(VR&E), Veterans Health Administration (VHA) or National Cemetery Administration (NCA)).
Note: If you would like to file for multiple benefit types, you MUST complete a separate VA Form 20-0995 for each benefit type. Documents may be
submitted by mail, in person at a VA regional office, or electronically. VA recommends submitting correspondence electronically as this is the fastest
method of receipt. VA provides several tools to assist in electronic submission.
To learn more about how to submit compensation or pension documents and claims electronically, visit www.va.gov/disability/upload-supportingevidence. You can also go directly to AccessVA to digitally upload any correspondence using QuickSubmit. By visiting www.va.gov you can also check
your claim status and learn about other VA benefits.
Or, if you prefer to mail your correspondence, please use the related mailing address below:
Compensation & Loan Guaranty

Pension & Survivors

Fiduciary

Department of Veterans Affairs
Compensation Intake Center
P.O. Box 4444
Janesville, WI 53547
Toll Free Phone: 1-800-827-1000
Toll Free Fax: (844) 531-7818

Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, WI 53547
Toll Free Phone: 1-800-827-1000
Toll Free Fax: (844) 655-1604

Department of Veterans Affairs
Fiduciary Intake Center
P.O. Box 5211
Janesville, WI 53547
Toll Free Phone: 1-800-827-1000
Toll Free Fax: (888) 581-6826

Insurance

National Cemetery Administration

Veteran Readiness & Employment

Department of Veterans Affairs
ATTN: Insurance Center
P.O. Box 5209
Janesville, WI 53547
https://insurance.va.gov/Home/IDU
Toll Free Phone: 1-800-669-8477

Department of Veterans Affairs
NCA FP Evidence Intake Center
P.O. Box 5237
Janesville, WI 53547

Department of Veterans Affairs
VR&E Intake Center
P.O. Box 5210
Janesville, WI 53547
Toll Free Phone: 1-800-827-1000

VA FORM
XXX XXXX

20-0995

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For Education Claims, Only:
Education
To determine jurisdiction via the addresses listed here, visit...
Buffalo Regional Processing Office
P.O. Box 4616
Buffalo, NY 14240-4616

Muskogee Regional Processing Office
P.O. Box 8888
Muskogee, OK 74402-8888

If You Need Assistance:
You may contact your accredited representative (attorney, claims agent, and Veterans Service Organization (VSO) representative) to assist you in
completing this form. If you have not already selected a representative or if you want to change your representative, a searchable database of VA
recognized VSOs, VA-accredited attorneys, claims agents, and VSO representatives is available at www.va.gov/ogc/apps/accreditation/index.asp.
You may also contact your State Department(s) of Veterans Affairs at www.va.gov/statedva.htm.
You can also ask VA to help you fill out the form by contacting us at the number provided on your decision notification letter or at 1-800-827-1000.
Before you contact us, please make sure you gather the necessary information and materials (decision notification letter, etc.), and complete as much of
the form as you can.
You are entitled to a hearing at any time in the claims process. If you wish to have a hearing, you can contact us online through Ask VA:
https://ask.va.gov or call us toll-free at 1-800-827-1000 (TTY: 711).
General Information:
Note: Regarding Fees for Claims: Generally, an accredited attorney or claims agent can ONLY charge claimants a fee after the VA has issued a
decision on a claim. Section 5904, Title 38 United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions
regarding fees, that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding
before the VA with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may
charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the
attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.
SPECIFIC INSTRUCTIONS FOR DECISION REVIEW REQUEST: SUPPLEMENTAL CLAIM
Item 1: Benefit Type
This form may only be completed for review of an issue(s) related to one benefit type. Select only one benefit type in Item 1. If you would like to file for
multiple benefit types, you must complete a separate VA Form 20-0995 for each benefit type.
Section I and II: Veteran and Claimant's Identifying Information
It will assist VA if you provide all the personal information in Section I, if you are the veteran, or Section II, if you are a non-veteran. However, if you
provide certain information specific to the veteran/claimant such as the last name, Social Security Number or VA file number, VA will be able to identify
the claimant in our system and would not consider this request incomplete if other information in Section I or II, such as the address or telephone number,
is excluded.
Section III: Homeless Information
If you are currently homeless or at risk of becoming homeless, complete Items 20A through 20D, as appropriate to your living situation.
Note: If you need help because of domestic violence, call the National Domestic Violence hotline 800-799-7233 (TTY: 800-787-3224) or text "START"
to 88788. Staff are there to help 24 hours a day, 7 days a week. All conversations are private and confidential.
Section IV: Issue(s) for Supplemental Claim
The purpose of this section is for you to identify, in Item 21, each issue decided by VA that you would like VA to review as a supplemental claim.
Please refer to your decision notification letter(s) for a list of adjudicated issues. You should also enter the date of VA's decision notice letter for each
issue, if possible. Only those issue(s) that you list on this form will be considered as part of your supplemental claim. For those issues you do not list on
this form, you will still have one year from the date of the decision notification letter to file a supplemental claim to maintain eligibility for the earliest
effective date for any granted benefits. For proper processing and in order to receive consideration for the earliest effective date possible, if you are filing
a supplemental claim within one-year of a decision from the United States Court of Appeals for Veterans Claims, United States Court of Appeals for the
Federal Circuit, or Supreme Court of the United States, identify the date of the court decision in Item 21B and attach a copy of the decision with this
form.
If you are responding to 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. To participate
in the modernized review system, you must submit this form within 60 days from the date of the SOC or SSOC and list the issue(s) in the SOC or SSOC
for which you are seeking review under Item 21. Your selection of the supplemental claim option does not prevent you from changing the review option
(in accordance with applicable procedures) before VA renders the supplemental claim decision on an issue. You cannot return to the legacy system for
any issue(s) you withdraw.
VA FORM 20-0995, XXX XXXX

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Section V: New and Relevant Evidence
For your supplemental claim to be complete, you must submit additional evidence that is NEW AND RELEVANT to support granting the benefit(s)
sought or you must identify existing relevant records that you would like VA to obtain. (NEW evidence means information not previously submitted to
VA, and RELEVANT evidence means information that tends to prove or disprove a matter at issue in the claim).
If you know of evidence not in your possession and want VA to try to obtain it for you, give VA enough information about the evidence so that we can
request it from the person or agency that has it. List all relevant evidence in the custody of a VA medical center (VAMC) or other Federal department or
agency. VA will retrieve relevant records from a Federal facility or VAMC that you adequately identify and authorize VA to obtain. If the holder of the
evidence declines to give it to VA, asks for a fee to provide it, or otherwise cannot get the evidence, VA will notify you and provide you with an
opportunity to submit the information or evidence.
VA will make every reasonable effort to obtain relevant records not held by a Federal facility that you adequately identify and authorize VA to obtain.
These may include records from State or local governments and privately held evidence and information you tell us about, such as private doctor or
hospital records from current or former employers.
Note 1: Unless your supplemental claim (www.va.gov/decision-reviews/supplemental-claim/) is based on a change in law, you'll need to submit
supporting evidence that's new and relevant for your application to be complete. You can also identify evidence you'd like us to gather for you.
Note 2: If you would like VA to attempt to obtain your private provider (excluding community care (paid for by VA). or VA Vet Center health
records, VA requires your consent by completing VA Forms 21-4142, Authorization to Disclose Information to VA, and 21-4142a, General Release for
Medical Provider Information to VA. VA forms are available at www.va.gov/vaforms.
Section VI: 5103 Notice of Acknowledgment
For Compensation, Pension, Dependency Indemnity Compensation (DIC), and Accrued benefit claims: If you are filing for review of an issue more
than one year after VA provided notice of our decision, please visit one of these pages on VA.gov to review the 38 U.S.C. 5103 information regarding
evidence necessary to substantiate your claim:

•
•

Evidence to support a claim for Veterans Disability Compensation and related Compensation benefits:
https://www.va.gov/disability/how-to-file-claim/evidence-needed/
Evidence to support a claim for VA pension, DIC, or accrued benefits:
https://www.va.gov/resources/evidence-to-support-va-pension-dic-or-accrued-benefits-claims/

Then, check the "YES" checkbox in Item 23 to confirm your receipt of this information. If you cannot review the information online and would like the
information mailed to you, check the "NO" checkbox in Item 23 and VA will send you this notice through the mail.
Section VII: Option for Veterans Benefit Administration (VBA) to notify VHA about Certain Upcoming Event(s) during the Claim and/or
Appeal Process
VHA provides free treatment for mental and physical health conditions related to experiences of Military Sexual Trauma (MST). These services are
available to individuals with veteran status and most former service members with an Other Than Honorable or uncharacterized (entry-level) discharge,
even if your claim for service connection is denied. To learn more, including how to access this care, go to www.mentalhealth.va.gov/mst or contact the
VHA MST Coordinator at a VA medical facility near you.
If you are filing a claim for compensation for a condition due to a personal traumatic event(s) involving MST and you are registered and/or enrolled for
VHA health care, you have the option for VBA to electronically notify VHA about certain upcoming event(s) during your claim and/or appeal process. If
you would like VBA to send these electronic notifications to VHA, please indicate your decision by selecting a checkbox in Item 24. A response is not
required. VBA will not send electronic notifications to VHA without your consent. If you do not respond, VBA will not send electronic notifications to
VHA, nor will there be a change in your prior decision.
Section VIII, IX, X, and XI: Certification and Signatures
Please be sure to sign this supplemental claim, certifying that the statements on the form are true and correct to the best of the veteran/claimant's or
authorized representative's knowledge and belief.
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 VA benefits, verification of identity and status, and
personnel administration) as identified in the following VA systems of records published in the Federal Register: 58/VA21/22/28, Compensation, Pension, Education and Veterans
Readiness and Employment Records -VA; 55VA26 Loan Guaranty Home, Condominium and Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant
Records, and Vendee Loan Applicant Records -VA; and 36VA29, Veterans and Armed Forces Personnel Programs of Government Life Insurance -VA. Your obligation to respond is
required to obtain or retain benefits. VA uses your SSN to identify your claims file. Providing your SSN will help ensure that your records are properly associated with your claim file.
Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing
to provide his or her SSN unless the disclosure of the SSN is required by a 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 maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is
subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
control Number. The OMB control number for this project is 2900-0886, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average
15 minutes per respondent, per year, 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 and any other aspect of this collection of information, including suggestions for reducing the
burden to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0886 in any correspondence. Do not send your completed
VA Form 20-0995 to this email address.
VA FORM 20-0995, XXX XXXX

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OMB Control No. 2900-0886
Respondent Burden: 15 minutes
Expiration Date: XX/XX/20XX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

DECISION REVIEW REQUEST: SUPPLEMENTAL CLAIM
IMPORTANT: Please read the Privacy Act and Respondent Burden information on page 3 before completing
the form. Use this form to submit a claim if you disagree with a decision you received. For more information
you can contact us online through Ask VA: https://ask.va.gov/ or call us toll-free at 1-800-698-2411 (TTY:711).
If you prefer you may complete and submit the form online by using the addresses and weblinks listed in the
Instructions, Page 1 or 2.
1. BENEFIT TYPE (PLEASE CHECK ONLY ONE BOX)
Note: If you would like to file for multiple benefit types, you must complete a separate VA Form 20-0995 for each benefit type.
COMPENSATION

PENSION/DIC/SURVIVORS BENEFITS

FIDUCIARY

EDUCATION

LOAN GUARANTY

LIFE INSURANCE

VETERAN READINESS AND EMPLOYMENT

NATIONAL CEMETERY ADMINISTRATION

VETERANS HEALTH ADMINISTRATION (NOTE: If checked, specify in the space provided below, which benefit type you are claiming for VHA. (e.g., Travel/Mileage
Reimbursement, Medical Treatment Reimbursement, Health Care Eligibility, Clothing Allowance, etc.)

SECTION I: VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and completely fill
in each applicable checkbox to help expedite processing of the form.
2. VETERAN'S NAME (First, Middle Initial, Last)
5. DATE OF BIRTH (MM/DD/YYYY)

3. SOCIAL SECURITY NUMBER

4. VA FILE NUMBER (If applicable)

6. SERVICE NUMBER (If applicable)

7. VA INSURANCE POLICY NUMBER (If applicable)

8. MAILING ADDRESS (Number, street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

9. TELEPHONE NUMBER (Optional) (Include Area Code)

10. E-MAIL ADDRESS (Optional)

Enter International Phone Number (If applicable)

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION
(Complete this section ONLY IF the claimant is NOT the veteran)
11. CLAIMANT'S NAME (First, Middle Initial, Last) (If other than veteran)

12. SOCIAL SECURITY NUMBER

13. VA FILE NUMBER (If applicable)

14. DATE OF BIRTH (MM/DD/YYYY)

15. VA INSURANCE POLICY NUMBER (If applicable)

16. RELATIONSHIP TO VETERAN (Check one)
SPOUSE

CHILD

FIDUCIARY

PARENT

OTHER (Specify)

17. MAILING ADDRESS (Number, street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

18. TELEPHONE NUMBER (Optional) (Include Area Code)

ZIP Code/Postal Code
19. E-MAIL ADDRESS (Optional)

Enter International Phone Number (If applicable)
VA FORM
XXX XXXX

20-0995

SUPERSEDES VA FORM 20-0995, SEP 2022.

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SECTION III: HOMELESS INFORMATION
IMPORTANT: The following questions (Items 20A through 20D) should ONLY be completed if you are currently homeless or at risk of becoming
homeless. If this item does not apply to you, skip to Section IV.
20A. ARE YOU CURRENTLY HOMELESS OR AT RISK OF BECOMING HOMELESS?
YES (If "Yes," complete Items 20B through 20D regarding your living situation)
NO

(If "No," skip to Item 21)

20B. WHICH OF THESE STATEMENTS BEST DESCRIBES YOUR LIVING
SITUATION? (Select all that apply)
I LIVE OR SLEEP IN A PLACE THAT IS NOT MEANT FOR REGULAR
SLEEPING (e.g., a car, park, abandoned building, bus station, train station,
airport or camp ground)
I LIVE IN A SHELTER (e.g., a hotel or motel that is meant for temporary
stays)
I AM STAYING WITH A FRIEND OR FAMILY MEMBER, BECAUSE I AM
UNABLE TO OWN A HOME RIGHT NOW
IN THE NEXT 30 DAYS, I WILL HAVE TO LEAVE A FACILITY, LIKE A
HOMELESS SHELTER
IN THE NEXT 30 DAYS, I WILL LOSE MY HOME
Note: This selection includes any house, apartment, trailer, or other living
space that you own, rent, or live in without paying rent, any hotels or
motels that are meant for temporary stays, or a living space that you share
with others.)
NONE OF THESE SITUATIONS APPLY TO ME
Note: We understand that you may have other housing risks not listed here. If
you feel comfortable sharing more about your situation, you can check `other'
and specify in the space provided. Or you can check `other' and not include any
details. We will use this information only to prioritize your request.
OTHER (Specify)

20C. POINT OF CONTACT (Name of person VA can contact in order to get in touch with you) 20D. POINT OF CONTACT TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number
(If applicable)

SECTION IV: ISSUE(S) FOR SUPPLEMENTAL CLAIM
21. YOU MUST LIST EACH ISSUE DECIDED BY VA THAT YOU WOULD LIKE VA TO REVIEW AS PART OF YOUR SUPPLEMENTAL CLAIM (Note: Refer
to your decision notice(s) for a list of adjudicated issues. For each issue, identify the date of VA's decision.)
If you are responding to a Statement of the Case (SOC) or a Supplemental Statement of the Case (SSOC): By submitting this form, I agree to participate
in the modernized review system for the following issues decided in a SOC or SSOC. I am withdrawing the eligible appeal issues listed in Item 21A in their
entirety, and any associated hearing requests, from the legacy appeals system. I understand I cannot return to the legacy appeals system for the issue(s)
withdrawn.
21A. SPECIFIC ISSUE(S)

VA FORM 20-0995, XXX XXXX

21B. DATE OF VA DECISION NOTICE

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SECTION V: NEW AND RELEVANT EVIDENCE
IMPORTANT: To complete your application, you must submit new and relevant evidence to VA or tell us about new and relevant evidence that VA can assist you in
gathering in support of your supplemental claim. If you have records in your possession, attach the records to this form. List your name and file number on each
page. If you would like VA to obtain non-Federal records, review your decision notification letter or read the instructions for this section on Page 3 that lists the
appropriate forms to complete and submit those forms to VA with this request form. Note: Unless your supplemental claim is based on a change in law, you'll
need to submit supporting evidence that's new and relevant for your application to be complete. You can also identify evidence you'd like us to gather for you.
22A. IDENTIFY WHERE YOU HAVE RECEIVED TREATMENT (Check all that apply)
PRIVATE HEALTH CARE PROVIDER (including non-Federal records)
VA VET CENTER
COMMUNITY CARE (Paid for by VA)
VA MEDICAL CENTER(S) (VAMC) AND COMMUNITY-BASED OUTPATIENT CLINICS (CBOC)
DEPARTMENT OF DEFENSE (DOD) MILITARY TREATMENT FACILITY(IES) (MTF)
OTHER (Specify):________________________________________________________________________________________________________________________

Note: VA has access to VAMC, CBOC, and MTF records. A consent form is not needed. However, if you would like VA to attempt to obtain your private provider
(excluding community care (paid for by VA) or VA Vet Center health records, VA requires your consent by completing VA Forms 21-4142, Authorization to
Disclose Information to VA, and 21-4142a, General Release for Medical Provider Information to VA. VA forms are available at www.va.gov/vaforms.

Note: If treatment began from 2005 to present, you do not need to provide in Item 22C the date(s) of treatment.
22B. NAME AND LOCATION OF THE
TREATMENT FACILITY

22C. DATE(S) OF TREATMENT
(Approximate dates are acceptable)
(MM-YYYY)

22D. CHECK THE BOX IF YOU DO NOT
HAVE DATE(S) OF TREATMENT

Don't have date

Don't have date

Don't have date

SECTION VI: 5103 NOTICE OF ACKNOWLEDGMENT
(This section applies to Compensation, Pension, DIC, and Accrued benefit claims only.
Note: If we issued your decision within the past year, skip to Section VII
23. FOR SPECIFIC EVIDENCE YOU NEED TO PROVIDE WITH YOUR CLAIM, VISIT ONE OF THESE PAGES ON www.va.gov.
• Evidence to support a claim for Veterans Disability Compensation and related Compensation benefits: https://www.va.gov/disability/how-to-file-claim/evidence-needed/.
• Evidence to support a claim for VA pension, DIC, or accrued benefits: https://www.va.gov/resources/evidence-to-support-va-pension-dic-or-accrued-benefits-claims/.
I CERTIFY THAT I HAVE REVIEWED THE NOTICE OF EVIDENCE THAT RELATES TO MY CLAIM.
YES

NO (If you check "No," VA will send the 5103 notice to you via mail.)

SECTION VII: OPTION FOR VETERANS BENEFITS ADMINISTRATION (VBA) TO NOTIFY VETERANS HEALTH ADMINISTRATION
(VHA) ABOUT CERTAIN UPCOMING EVENT(S) DURING THE CLAIM AND OR APPEAL PROCESS
IMPORTANT: For information on VHA health care services, visit www.va.gov/health-care/about-va-health-benefits. To learn more about VHA health care services
available related to military sexual trauma (MST), you can contact a VHA MST Coordinator. A list is available at www.mentalhealth.va.gov/msthome/vha-mstcoordinators.asp or you can contact your local VA medical facility and ask to speak to the MST Coordinator.)
24. If you are filing a claim for compensation for a condition due to a personal traumatic event(s) involving MST and you are registered and/or enrolled for VHA health care,
you have the option for VBA to electronically notify VHA about certain upcoming event(s) during your claim and/or appeal process. These event(s) are any scheduled
compensation and pension (C&P) examination, hearing before the Board of Veterans' Appeals, and any decision notification. When notified, VHA will place an indicator in your
medical record to alert VA health care providers that these event(s) are scheduled to occur. Notifications to VHA would only indicate the type of event(S) and potential time
frame, not any details specific to your claim. The indicator in your medical record would not identify your claim as MST-related, but at this time, only claimants filing MSTrelated claims are provided this notification option. For this reason, providers may know that the indicator is in relation to an MST-related claim. The decision to consent, not
consent, or revoke prior consent into the automatic notification system will not affect the status or outcome of your claim. A response is not required. If you do not
respond, VBA will not send electronic notifications to VHA, nor will the outcome of your claim be impacted. If you would like VBA to send these electronic notifications to VHA,
please indicate your consent by selecting a check box below.
A. I CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENT(S) RELATED TO MY CLAIM AND/OR APPEAL (Note: I understand that an
indicator for these event(s) will appear in my VHA medical record.)
B. I DO NOT CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENT(S) RELATED TO MY CLAIM AND/OR APPEAL (Note: I understand that
an indicator for these event(s) will not appear in my VHA medical record.)
C. I REVOKE PRIOR CONSENT TO HAVE VBA NOTIFY VHA ABOUT CERTAIN UPCOMING EVENT(S) RELATED TO MY CLAIM AND/OR APPEAL (Note: I
understand that in the future, notice of these event(s) will no longer appear in my VHA medical record.)
D. NOT APPLICABLE AND/OR NOT ENROLLED OR REGISTERED IN VHA HEALTH CARE

Note: You have the option to modify your previous selection at any time. Mail your correspondence to: Department of Veterans Affairs, Compensation
Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
VA FORM 20-0995, XXX XXXX
Page 6

SECTION VIII: CERTIFICATION AND SIGNATURE
I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
25A.VETERAN/CLAIMANT'S SIGNATURE

25B. DATE SIGNED (MM/DD/YYYY)

SECTION IX: WITNESSES TO SIGNATURE
(Note: Only use this section if the veteran/claimant used an "X" in Item 25A)
26B. PRINTED NAME AND ADDRESS OF FIRST WITNESS

26A. SIGNATURE OF THE FIRST WITNESS

Name:
Address:
27B. PRINTED NAME AND ADDRESS OF SECOND WITNESS

27A. SIGNATURE OF THE SECOND WITNESS

Name:
Address:

SECTION X: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (Note: Required only if Item 25A is blank.)
NOTE 1: An alternate signer signature will not be accepted unless a valid VA Form 21-0972, Alternate Signer Certification, is of record or attached to this
request.
NOTE 2: For insurance appeals, either VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, VA Form 21-22A,
Appointment of Individual as Claimant's Representative, OR VA Form 21P-555, Certificate of Legal Capacity to Receive and Disburse Benefits and Fee
Authorization, needs to be of record to allow an alternate signer to sign on behalf of the claimant.
I CERTIFY THAT by signing on behalf of the claimant, that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on
behalf of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a spouse
or other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND, that the
claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to certify that
the statements made on the form are true and complete; OR, is physically unable to sign this form.
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that VA
may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant if
necessary. Examples of evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN); a certificate or
order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/time stamp; copy of
documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and your authority as attorney
in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the care of the claimant
indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
28A. ALTERNATE SIGNER'S SIGNATURE

28B. DATE SIGNED (MM/DD/YYYY)

SECTION XI: POWER OF ATTORNEY (POA) SIGNATURE
(Note: This section does not apply to insurance claims)
I CERTIFY THAT the claimant has authorized the undersigned representative to file this claim on behalf of the claimant and that the claimant is aware and
accepts the information provided in this document. I certify that the claimant has authorized the undersigned representative to state that the claimant
certifies the truth and completion of the information contained in this document to the best of claimant's knowledge.
NOTE: A POA's signature will not be accepted unless at the time of submission of this claim a valid VA Form 21-22, or VA Form 21-22a, indicating the
appropriate POA is of record with VA.
29A. POA/AUTHORIZED REPRESENTATIVE'S SIGNATURE

29B. DATE SIGNED (MM/DD/YYYY)

29C. ACCREDITATION NUMBER

29D. DATE LAST VA FORM 21-22 OR VA FORM 21-22A WAS SUBMITTED
(If known)

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or
evidence of a material fact, knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.

VA FORM 20-0995, XXX XXXX

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