VA Form 21-0966 Intent to File a Claim for Compensation and/Or Pension, or Survivors Pension and/Or Dic

What Is VA Form 21-0966?

VA Form 21-0966, Intent to File A Claim for Compensation and/or Pension, or Survivors Pension and/or DIC is a document notifying the Department of Veterans Affairs (VA) of the intention to file a claim for the VA compensation and pension benefits, including the Dependency and Indemnity Compensation (DIC) - a monetary benefit paid to survivors of service members who died from a service-related disease or injury or died in the line of duty.

When the VA 21-0966 is filed, it gives the future claimant more time to gather information in support of the claim. Additionally, it protects the earliest effective date for benefits resulting from the claim. The date when the VA receives this form is considered the effective date. However, the form must be submitted within a year.

The latest version of the form was released by the VA in August 2018 with all previous editions obsolete. A fillable VA Form 21-0966 is available for digital filing and download below.

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OMB Control No. 2900-0826
Respondent Burden: 15 minutes
Expiration Date: 08/31/2021
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION,
OR SURVIVORS PENSION AND/OR DIC
(This Form Is Used to Notify VA of Your Intent to File for the General Benefit(s) Checked Below)
NOTE: Please read the Privacy Act and Respondent Burden below before completing the form.
SECTION I: CLAIMANT/VETERAN IDENTIFICATION
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to expedite processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)
2. CLAIMANT'S SOCIAL SECURITY NUMBER
4. VETERAN'S DATE OF BIRTH (MM,DD,YYYY)
3. VA FILE NUMBER (If applicable)
Month
Day
Year
5. VETERAN'S NAME (First, Middle Initial, Last) (If different from claimant)
6. VETERAN'S SOCIAL SECURITY NUMBER
7. VETERAN'S SEX
8. VETERAN'S SERVICE NUMBER (If applicable)
MALE
FEMALE
9. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
10. HAS THE VETERAN EVER FILED A
12. EMAIL ADDRESS (If applicable)
11.TELEPHONE NUMBER (Include Area Code)
CLAIM WITH VA?
YES
NO
SECTION II: 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. I intend to file for the general benefit(s) checked below: (Choose all that apply)
PENSION
COMPENSATION
NOTE: Only check the box below if you are a surviving dependent of the veteran.
SURVIVORS 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 through eBenefits at www.ebenefits.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 II as possible. VA cannot process this form if we cannot identify the claimant and veteran.
SECTION III: DECLARATION OF INTENT
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.
14A. SIGNATURE OF CLAIMANT/AUTHORIZED REPRESENTATIVE
14B. DATE SIGNED (MM,DD,YYYY)
15. 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.)
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 Vocational Rehabilitation 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 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 15 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.
EXISTING STOCK OF VA FORM 21-0966, MAR 2017,
VA FORM
21-0966
WILL BE USED.
AUG 2018
OMB Control No. 2900-0826
Respondent Burden: 15 minutes
Expiration Date: 08/31/2021
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
INTENT TO FILE A CLAIM FOR COMPENSATION AND/OR PENSION,
OR SURVIVORS PENSION AND/OR DIC
(This Form Is Used to Notify VA of Your Intent to File for the General Benefit(s) Checked Below)
NOTE: Please read the Privacy Act and Respondent Burden below before completing the form.
SECTION I: CLAIMANT/VETERAN IDENTIFICATION
NOTE: You can either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to expedite processing of the form.
1. CLAIMANT'S NAME (First, Middle Initial, Last)
2. CLAIMANT'S SOCIAL SECURITY NUMBER
4. VETERAN'S DATE OF BIRTH (MM,DD,YYYY)
3. VA FILE NUMBER (If applicable)
Month
Day
Year
5. VETERAN'S NAME (First, Middle Initial, Last) (If different from claimant)
6. VETERAN'S SOCIAL SECURITY NUMBER
7. VETERAN'S SEX
8. VETERAN'S SERVICE NUMBER (If applicable)
MALE
FEMALE
9. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
10. HAS THE VETERAN EVER FILED A
12. EMAIL ADDRESS (If applicable)
11.TELEPHONE NUMBER (Include Area Code)
CLAIM WITH VA?
YES
NO
SECTION II: 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. I intend to file for the general benefit(s) checked below: (Choose all that apply)
PENSION
COMPENSATION
NOTE: Only check the box below if you are a surviving dependent of the veteran.
SURVIVORS 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 through eBenefits at www.ebenefits.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 II as possible. VA cannot process this form if we cannot identify the claimant and veteran.
SECTION III: DECLARATION OF INTENT
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.
14A. SIGNATURE OF CLAIMANT/AUTHORIZED REPRESENTATIVE
14B. DATE SIGNED (MM,DD,YYYY)
15. 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.)
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 Vocational Rehabilitation 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 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 15 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.
EXISTING STOCK OF VA FORM 21-0966, MAR 2017,
VA FORM
21-0966
WILL BE USED.
AUG 2018

Download VA Form 21-0966 Intent to File a Claim for Compensation and/Or Pension, or Survivors Pension and/Or Dic

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VA Form 21-0966 Instructions

VA intent to file a claim form consists of three sections:

  1. Section I - Claimant/Veteran Identification - the claimant's full name, social security number, and VA file number (if applicable), the veteran's date of birth, the veteran's full name, social security number, sex, and service number, the current mailing address, the telephone number, the email address. The applicant must also state, if the veteran has ever filed a claim with the VA.
  2. Section II - General Benefit Election. It is required to select one or more of the general benefits - a compensation or a pension. If the boxes remain unchecked, the VA will not be able to use the form to establish an effective date. If the future claimant is a surviving dependent of the veteran, the box «Survivors pension and/or Dependency and Indemnity Compensation (DIC)» must be checked.
  3. Section III - Declaration of Intent. The claimant indicates the intent to apply for one or more general benefits acknowledging that this form is not a claim for benefits and that the complete application for the benefits must be received within one year from the date the VA receives the form. The claimant or the authorized representative must sign the form and write down the actual date. If the form was completed by a Veteran Service Organization representative, an agent, or an attorney, the form must also contain the individual's name.

How to File VA Form 21-0966?

There are three ways to file the VA 21-0966 form:

  • Online through eBenefits. First, it is necessary to initiate a claim. The future claimant completes the personal information page to establish an effective date. This gives an applicant one year to complete the filing process;
  • A paper form can be mailed to the VA pension management center. Their mailing addresses are listed below; and
  • In person or over the phone. It is allowed to call the VA's National Call Center or visit one of the VA's regional benefit offices, which can be located at eBenefits website.

Where to Send VA Form 21-0966?

There are three VA regional pension management centers:

  • Philadelphia VA Regional Office (serves Connecticut, Delaware, Florida, Georgia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Vermont, Virginia, West Virginia and all foreign countries not included under the St. Paul VA Regional Office);
  • Milwaukee VA Pension Center (serves Alabama, Arkansas, Indiana, Illinois, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Tennessee, Wisconsin);
  • St. Paul VA Regional Office (serves Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, North Dakota, New Mexico, Nevada, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming, Central America, Mexico, South America, and the Caribbean).

The current address for mailing the VA Form 21-0966 is the Department of Veterans Affairs, Claims Intake Center (Attention: Philadelphia Pension Center) PO Box 5206, Janesville, WI 53547-5206.

Milwaukee VA Pension Center: Department of Veterans Affairs, Claims Intake Center Attention: Milwaukee Pension Center, PO Box 5192 Janesville, WI 53547-5192

St. Paul VA Regional Office: Department of Veterans Affairs, Claims Intake Center Attention: St. Paul Pension Center, PO BOX 5365 Janesville, WI 53547-5365

Video Instructions for VA Form 21-0966

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