VA Form 20-0995

Step 1 of 7

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-supporting-evidence. 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

For Education Claims, Only:

Education
To determine jurisdiction via the addresses listed here, visit: https://benefits.va.gov/gibill/regional_processing.asp
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.

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 05/31/2027. 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 VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0886 in any correspondence. Do not send your completed VA Form 20-0995 to this email address.

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)

20B. I LIVE OR SLEEP IN A PLACE

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)

20B. I LIVE IN A SHELTER

I LIVE IN A SHELTER (e.g., a hotel or motel that is meant for temporary stays)

20B. I AM STAYING WITH A FRIEND

I AM STAYING WITH A FRIEND OR FAMILY MEMBER, BECAUSE I AM UNABLE TO OWN A HOME RIGHT NOW

20B. IN THE NEXT 30 DAYS

IN THE NEXT 30 DAYS, I WILL HAVE TO LEAVE A FACILITY, LIKE A HOMELESS SHELTER

20B. IN THE NEXT 30 DAYS, I WILL LOSE MY HOME

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.)

20B. NONE OF THESE SITUATIONS APPLY TO ME

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.

20B. OTHER (Specify)

OTHER (Specify)

IF 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)

20D. International Phone Number

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)

21B. DATE OF VA DECISION NOTICE

21A. 1

21B. 1

21A. 2

21B. 2

21A. 3

21B. 3

21A. 4

21B. 4

21A. 5

21B. 5

21A. 6

21B. 6

21A. 7

21B. 7

21A. 8

21B. 8

21A. 9

21B. 9

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)

26A. SIGNATURE OF THE FIRST WITNESS

26B. PRINTED NAME AND ADDRESS OF FIRST WITNESS

Name:

Address:

27A. SIGNATURE OF THE SECOND WITNESS

27B. PRINTED NAME AND ADDRESS OF 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 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.