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Department of Veterans Affairs

Fill out VA Form 21-0966 online

Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC

VA Form 21-0966 tells the Department of Veterans Affairs that you plan to file a claim for disability compensation, Veterans Pension, survivors pension or Dependency and Indemnity Compensation (DIC). It is not a claim itself. If VA receives your completed application within one year of receiving this form, the application is treated as filed on the date VA received this form, which can set an earlier potential start date for benefits.

Fill out VA Form 21-0966Blank form from the VA

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Edition
MAY 2026
Pages
2
Fillable fields
57
Checked against the VA
November 8, 2026

GuruPDF is not affiliated with the Department of Veterans Affairs. This page explains the form in plain words; it is not legal or tax advice. Always check the official instructions before you file.

Who uses VA Form 21-0966

  • Veterans who plan to file a disability compensation claim
  • Veterans who plan to apply for Veterans Pension
  • Surviving dependents who plan to apply for survivors pension or DIC
  • Fiduciaries, alternate signers and other people completing the form for a claimant
  • Accredited attorneys, claims agents and VSO representatives with a valid power of attorney

Before you start

  • The Veteran's full name, Social Security number and date of birth
  • The Veteran's VA file number and service number, if there are any
  • If you are not the Veteran: your own name, Social Security number, date of birth and VA file number, if any
  • A mailing address, phone number and email address for the Veteran and, if different, the claimant
  • Which general benefit or benefits you plan to claim
  • If you sign for someone else: VA Form 21-0972, 21-22 or 21-22a already submitted to VA

How to fill out VA Form 21-0966

  1. Section I: Veteran's identification (Items 1-9)

    Enter the Veteran's name, Social Security number and date of birth. Item 3 asks whether the Veteran has ever filed a VA claim; if you answer yes, give the VA file number in Item 4. Add the service number (Item 6), mailing address (Item 7), phone number (Item 8, with a separate line for an international number) and email (Item 9). Tick the box next to Item 9 if you agree to receive electronic correspondence from VA about the claim.

  2. Section II: Claimant's identification (Items 10-18)

    Fill in this section only if the claimant is not the Veteran. Enter the claimant's name, Social Security number and whether they have filed a VA claim before (with the VA file number in Item 13 if yes). In Item 14, check one relationship to the Veteran: spouse, child, fiduciary, Veteran service officer, alternate signer, third-party or other. Then add the claimant's date of birth, mailing address, phone and email.

  3. Section III: General benefit election (Item 19)

    Check every general benefit you intend to file for: compensation, pension, or both. Check the survivors pension and/or DIC box only if you are a surviving dependent of the Veteran. The form warns that VA may not be able to use it to set an effective date if no benefit is selected.

  4. Section IV: Read the declaration

    By filing, you state your intent to apply for one or more general benefits. You also acknowledge that the form is not a claim, that you must file a complete application for each benefit, and that the application must reach VA within one year of the date VA receives this form.

  5. Sign and date (Items 20-21)

    The Veteran, the claimant or an authorized person signs in Item 20, which the form marks as required. Enter the date signed in Item 21 as MM/DD/YYYY.

  6. Representative's name (Item 22)

    If an attorney, claims agent or Veterans Service Organization is completing the form, print their name here. The form says this may be done only if a valid power of attorney has been completed.

After you fill it out

Mail the signed form to VA at the address printed on page 2 of the form. VA's intent to file page also lists other ways to notify VA: VA's own online tool on VA.gov, by phone or in person. After VA receives the form, it will give you the right application for the benefit you selected. You then have one year from the date VA receives this form to file that complete application.

Signing: Item 20 must be signed by the Veteran, the claimant or an authorized signer, and Item 21 must be dated. The form says it may be completed online or by hand but does not say whether a typed or digital signature is accepted on the PDF, so follow VA's instructions.

Watch out for

  • This form is not a claim. VA will not process a claim until you file a complete application for each benefit.
  • Check at least one benefit in Item 19. The form says VA may not be able to use it to set an effective date if you do not.
  • VA's online intent to file page says that if you sign for someone else, VA needs VA Form 21-0972, 21-22 or 21-22a showing you are authorized, submitted before the intent to file. The form itself says an attorney, agent or VSO may complete it only with a valid power of attorney.
  • VA says an intent to file is not set automatically when you apply online for Dependency and Indemnity Compensation, or for a Supplemental Claim for benefits other than disability. Those need a separate intent to file.

Questions about VA Form 21-0966

How long do I have to file my claim after sending this form?

One year from the date VA receives the form. If your completed application arrives within that year, VA treats it as filed on the date it received this form. After that year, the potential effective date expires.

Can I choose more than one benefit on one form?

Yes. You can check more than one benefit in Item 19, or send a separate VA Form 21-0966 for each benefit. If you later plan to claim a benefit type you did not select, VA says you need a new intent to file for it.

Do I need this form if I file my disability claim online?

VA says that starting a disability compensation claim or a Supplemental Claim for disability online, while signed in with an identity-verified account, notifies VA of your intent to file automatically. In that case you do not need to send a separate intent to file form.

Who fills in Section II?

Only a claimant who is not the Veteran. Item 14 lists the relationships: spouse, child, fiduciary, Veteran service officer, alternate signer, third-party or other. A Veteran filing for themselves leaves Section II blank.

What happens after VA receives the form?

VA will give you the application for the benefit you selected. You then have to complete and file that application for VA to decide your claim.

Official information

Page text last reviewed November 7, 2026.

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