VA Form 21-0966 - VA Claims

Section 1 of 6

Veteran Identification (Section I, Items 1 to 6)

1. Veteran's Name (First, Middle Initial, Last): *

2. Social Security Number:

4. VA File Number (if applicable): Provide if you have ever filed a claim with VA.

3. Have you ever filed a claim with VA?

Yes No

5. Date of Birth:

6. Veteran's Service Number (if applicable):

Section 2 of 6

Veteran Contact Information (Section I, Items 7 to 9)

7. Number and Street (or P.O. Box):

Apt./Unit Number:

City:

State/Province:

Country:

ZIP Code/Postal Code:

8. Telephone Number:

International Phone (if applicable):

9. E-mail Address (if applicable):

I agree to receive electronic correspondence from VA in regards to my claim.

Section 3 of 6

Claimant Identification (Section II, Items 10 to 15)

Complete this section ONLY if the claimant is NOT the veteran. Otherwise leave blank.

10. Claimant's Name (First, Middle Initial, Last):

11. Social Security Number:

13. VA File Number (if applicable):

15. Claimant's Date of Birth:

12. Have you ever filed a claim with VA?

Yes No

14. Relationship to Veteran (check one):

Spouse Child Fiduciary Veteran Service Officer Alternate Signer Third-Party Other

Section 4 of 6

Claimant Contact Information (Section II, Items 16 to 18)

Complete only if the claimant is not the veteran.

16. Number and Street (or P.O. Box):

Apt./Unit Number:

City:

State/Province:

Country:

ZIP Code/Postal Code:

17. Telephone Number:

International Phone (if applicable):

18. E-mail Address (if applicable):

I agree to receive electronic correspondence from VA in regards to my claim.

Section 5 of 6

General Benefit Election (Section III, Item 19)

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 below. Choose all that apply.

Compensation Pension Survivors Pension and/or Dependency and Indemnity Compensation (DIC)

Only check the Survivors Pension and/or DIC box if you are a surviving dependent of the veteran.

Section 6 of 6

Declaration of Intent and Signature (Section IV, Items 20 to 22)

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 this is not a claim for benefits, that I must file a complete application for each general benefit with VA before VA will process my claim, and that a complete application must be received within one year of the date VA receives this form.

20. Signature of Veteran / Claimant / Authorized Agent (type full legal name): * Typing your full name here acts as your electronic signature.

21. Date Signed: *

22. Name of Attorney, Agent, or Veterans Service Organization (VSO): Only completed by a VSO, attorney, or agent if a valid power of attorney is on file.