Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966)

VA Form 21-0966 is used by claimants and/or their authorized representatives to indicate intent to file a claim for disability benefits to establish an effective date for an award granted in association with a complete claim filed within one year of such form. VA uses this form to identify claimants in its internal business operational systems to record the date of receipt of this document for the purposes of establishing a date of claim for a complete claim that is filed within one year. VA also uses the information to furnish the claimant with the appropriate VA form or application for VA benefits.

The latest form for Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC (VA Form 21-0966) expires 2026-04-30 and can be found here.