Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1. VETERAN'S NAME (First, Middle Initial, Last)FirstMiddleLast2. VETERAN'S SOCIAL SECURITY NUMBER3. VA FILE NUMBER5. CLAIMANT'S NAME (First, Middle Initial, Last)FirstMiddleLast6. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) No. & Street Apt./Unit Number City State/ProvinceCountry ZIP Code/Postal Code7. TELEPHONE NUMBER (Include Area Code)8. E-MAIL ADDRESS (Optional)9. WOULD YOU LIKE TO RECEIVE A TELEPHONE CALL OR E-MAIL FROM A REPRESENTATIVE AT YOUR LOCAL REGIONAL OFFICE REGARDING YOUR NOD?YESNO(If you answered "Yes," VA will make up to two attempts to call you between 8:00 a.m. and 4:30 p.m. local time at the telephone number and time period you select below. Please select up to two time periods you are available to receive a phone call.)8:00 a.m. - 10:00 a.m.10:00 a.m. - 12:30 p.m.12:30 p.m. - 2:00 p.m.2:00 p.m. - 4:30 p.m.Phone number I can be reached at the above checked time: 10. SELECT ONE OF THE APPEALS PROCESSING METHODS BELOW (See Specific Instructions, Page 2, Section IV for additional information)Decision Review Officer (DRO) Review ProcessTraditional Appellate Review ProcessVETERAN'S SSN11. NOTIFICATION/DECISION LETTER DATEAService ConnectionEffective Date of AwardEvaluation of DisabilityOther (Please specify below)C13A. IN THE SPACE BELOW, OR ON A SEPARATE PAGE, PLEASE EXPLAIN WHY YOU FEEL WE INCORRECTLY DECIDED YOUR CLAIM, AND LIST ANY DISAGREEMENT(S) NOT COVERED ABOVE:13B. DID YOU ATTACH ADDITIONAL PAGES TO THIS NOD?YESNO (If so, how many?)Submit
