Personal Information

Veteran's Full Legal Name*
No dashes or spaces

If applicable, fill in your respective VA file number in the field below.

This is an optional field, please skip this if you do not know if you have a VA file number. If you are unsure if you have a VA File Number, it can be located on your Rating Decision Details found in your VA Documentation.

This is typically the same as your Social Security Number. No dashes or spaces.
Only include if your service number is different than your Social Security Number
Veteran's Date of Birth*
Are you the veteran named above?*
What is your name?
What is your Date of Birth?
Are you homeless?
Preferred Mailing Address*

Board Review Opinion

Please select one of the options below regarding your appeal:*

Issue(s) for Supplemental Claim

Do you have any SOCs or SSOCs that are being withdrawn from the legacy appeals process?*
List ONLY the body part affected, NOT the entire disability
Date of VA Decision Notice for Issue 1
MM/DD/YYYY
List ONLY the body part affected, NOT the entire disability
Date of VA Decision Notice for Issue 2
MM/DD/YYYY
List ONLY the body part affected, NOT the entire disability
Date of VA Decision Notice for Issue 3
MM/DD/YYYY
List ONLY the body part affected, NOT the entire disability
Date of VA Decision Notice for Issue 4
MM/DD/YYYY
List ONLY the body part affected, NOT the entire disability
Date of VA Decision Notice for Issue 5
MM/DD/YYYY
Do you have additional issues to include in the supplemental claim?
Include the body part and date of VA decision notice for each additional issue

Certification and Signature

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Date Signed*
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