VA SUPPLEMENTAL CLAIM REQUEST

Decision Review with New and Relevant Evidence

DEPARTMENT OF VETERANS AFFAIRS
Veterans Benefits Administration

SECTION 1: VETERAN IDENTIFICATION

Veteran's Full Legal Name: _______________________________________________

VA File Number: _______________________________________________

Social Security Number: _______________________________________________

Date of Birth: _______________________________________________

Current Mailing Address:
_______________________________________________
_______________________________________________
_______________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

SECTION 2: PRIOR DECISION INFORMATION

Date of Most Recent VA Decision: _______________________________________________

Type of Decision:
☐ Initial Rating Decision
☐ Higher-Level Review Decision
☐ Board of Veterans' Appeals Decision
☐ Supplemental Claim Decision
☐ Other: _______________________________________________

VA Regional Office that Issued Decision: _______________________________________________

Claim/Appeal Number (if known): _______________________________________________

SECTION 3: ISSUES FOR SUPPLEMENTAL REVIEW

List each issue from the prior decision that you are requesting supplemental review:

Issue 1:

Issue Description: _______________________________________________

Prior Decision Summary: _______________________________________________

Rating/Decision Received: _______________________________________________

Effective Date Received: _______________________________________________

Why Supplemental Claim is Appropriate:
☐ New evidence obtained that was not previously of record
☐ Relevant evidence identified that VA did not consider
☐ PACT Act created new presumption for this condition
☐ Change in law or regulation applies
☐ New medical diagnosis or opinion available

Issue 2:

Issue Description: _______________________________________________

Prior Decision Summary: _______________________________________________

Rating/Decision Received: _______________________________________________

Effective Date Received: _______________________________________________

Why Supplemental Claim is Appropriate:
☐ New evidence obtained that was not previously of record
☐ Relevant evidence identified that VA did not consider
☐ PACT Act created new presumption for this condition
☐ Change in law or regulation applies
☐ New medical diagnosis or opinion available

Issue 3:

Issue Description: _______________________________________________

Prior Decision Summary: _______________________________________________

Rating/Decision Received: _______________________________________________

Effective Date Received: _______________________________________________

Why Supplemental Claim is Appropriate:
☐ New evidence obtained that was not previously of record
☐ Relevant evidence identified that VA did not consider
☐ PACT Act created new presumption for this condition
☐ Change in law or regulation applies
☐ New medical diagnosis or opinion available

(Attach additional pages if requesting review of more issues)

SECTION 4: NEW AND RELEVANT EVIDENCE

A supplemental claim requires new and relevant evidence (38 CFR § 3.2501). Identify the new evidence being submitted:

Definition of "New and Relevant" Evidence:

New Evidence: Evidence not previously submitted to or obtained by VA in connection with the claim.

Relevant Evidence: Evidence that tends to prove or disprove a matter at issue in the claim.

New Evidence Summary:

Evidence Item 1:

Evidence Item 2:

Evidence Item 3:

SECTION 5: PACT ACT NEW PRESUMPTIONS

The PACT Act (Pub. L. 117-168) created new presumptive conditions. If your supplemental claim involves PACT Act presumptions, complete this section:

☐ This supplemental claim is based on PACT Act presumptions

Basis for PACT Act Supplemental Claim:

☐ Newly Presumptive Condition - Condition previously denied is now presumptive under PACT Act
☐ Toxic Exposure Presumption - 38 CFR § 3.320 toxic exposure risk activity applies
☐ Camp Lejeune Water Contamination - 38 CFR § 3.309(f) applies
☐ Burn Pit/Airborne Hazards - Service in covered locations under PACT Act
☐ Radiation Exposure - Expanded radiation presumptions

Previously Denied Condition Now Presumptive:
_______________________________________________

Relevant PACT Act Provision:
_______________________________________________

Dates and Locations of Qualifying Service:
_______________________________________________
_______________________________________________

PACT Act Presumptive Conditions List:

Respiratory Conditions (Post-9/11 Service):
☐ Asthma (diagnosed after 9/11/2001)
☐ Chronic bronchitis
☐ COPD
☐ Constrictive bronchiolitis
☐ Emphysema
☐ Granulomatous disease
☐ Interstitial lung disease
☐ Pleuritis
☐ Pulmonary fibrosis
☐ Sarcoidosis
☐ Chronic sinusitis
☐ Chronic rhinitis

Cancers:
☐ Head cancer (any type)
☐ Neck cancer (any type)
☐ Respiratory cancer
☐ Gastrointestinal cancer
☐ Reproductive cancer
☐ Lymphoma (any type)
☐ Lymphomatic cancer
☐ Kidney cancer
☐ Brain cancer
☐ Melanoma
☐ Pancreatic cancer
☐ Glioblastoma

SECTION 6: ARGUMENT FOR FAVORABLE DECISION

Why the New Evidence Warrants a Different Decision:

Summary of Argument:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

Addressing Prior Denial Reasons:

Reason 1 for Prior Denial:
_______________________________________________

How New Evidence Addresses This:
_______________________________________________
_______________________________________________

Reason 2 for Prior Denial:
_______________________________________________

How New Evidence Addresses This:
_______________________________________________
_______________________________________________

Reason 3 for Prior Denial:
_______________________________________________

How New Evidence Addresses This:
_______________________________________________
_______________________________________________

SECTION 7: NEXUS EVIDENCE

Medical Nexus Opinion:

☐ New nexus letter from treating physician attached
☐ New Independent Medical Examination (IME) report attached
☐ Requesting new VA Compensation & Pension (C&P) examination

If Nexus Letter Attached:

Medical Professional Name: _______________________________________________

Credentials: _______________________________________________

Specialty: _______________________________________________

Date of Opinion: _______________________________________________

Summary of Nexus Opinion:
_______________________________________________
_______________________________________________
_______________________________________________

Opinion Standard:
The medical opinion states that it is at least as likely as not (50% or greater probability) that:
_______________________________________________
_______________________________________________

SECTION 8: REQUEST FOR VA ASSISTANCE

Under 38 USC § 5103A, VA has a duty to assist in obtaining evidence.

☐ Request VA obtain federal records:

☐ Request VA obtain private records:

☐ Request new C&P examination

Reason for new examination:
_______________________________________________
_______________________________________________

SECTION 9: EFFECTIVE DATE CONSIDERATIONS

Requested Effective Date:

Date Requested: _______________________________________________

Basis for Effective Date:

☐ Within One Year of Decision - Filing within one year of prior decision
- Prior Decision Date: _______________________________________________
- Preserves effective date from original claim

☐ Continuously Prosecuted Claim - Claim has been continuously prosecuted since:
- Original Claim Date: _______________________________________________

☐ PACT Act Liberalizing Law - 38 CFR § 3.114 applies
- Date condition became presumptive: _______________________________________________
- Effective date should be date of original claim or date of PACT Act, whichever is later

☐ New Service Records - 38 CFR § 3.156(c) applies
- Date of original claim: _______________________________________________

☐ Other basis: _______________________________________________

SECTION 10: DUTY TO ASSIST ERRORS IN PRIOR DECISION

If VA failed to fulfill its duty to assist in the prior decision, identify the errors:

☐ VA failed to obtain relevant federal records
☐ VA failed to obtain relevant private records
☐ VA failed to provide adequate C&P examination
☐ VA failed to obtain military personnel records
☐ VA failed to request service treatment records
☐ VA failed to consider lay evidence of record
☐ Other duty to assist error: _______________________________________________

Detailed Explanation:
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 11: OPT-IN FROM LEGACY APPEALS SYSTEM

If you have a legacy appeal (filed before February 19, 2019), you may opt into the modern appeals system:

☐ Opting into AMA from Legacy Appeal

Legacy Appeal Information:
- Docket Number: _______________________________________________
- Date of Original NOD: _______________________________________________
- Current Status: _______________________________________________

I understand that by opting into AMA:
☐ My legacy appeal will be withdrawn
☐ I will receive a new decision under the AMA process
☐ My effective date will generally be preserved if filed within the applicable timeframe

SECTION 12: ATTACHMENTS CHECKLIST

Required:
☐ VA Form 20-0995 (Decision Review Request: Supplemental Claim)
☐ Copy of prior VA decision
☐ New and relevant evidence (at least one item required)

Evidence Attached:
☐ New medical records
☐ New nexus letter/medical opinion
☐ New buddy statement(s)
☐ New lay statement(s)
☐ New service records
☐ New employment records
☐ New diagnostic test results
☐ Photographs/imaging
☐ Other new evidence: _______________________________________________

Authorization Forms:
☐ VA Form 21-4142 (Authorization to Disclose Information)
☐ VA Form 21-4142a (General Release for Medical Provider Information)
☐ VA Form 21-22 or 21-22a (Representative Appointment)

SECTION 13: REPRESENTATIVE INFORMATION

☐ Veteran is self-represented (pro se)
☐ Veteran is represented

Representative Name: _______________________________________________

Organization: _______________________________________________

Phone Number: _______________________________________________

Email: _______________________________________________

VA Form 21-22 or 21-22a on File: ☐ Yes ☐ No

SECTION 14: CERTIFICATION AND SIGNATURE

I certify that:
1. I am submitting new and relevant evidence with this supplemental claim
2. The information provided is true and correct to the best of my knowledge
3. I understand that knowingly making false statements is punishable under federal law

Veteran's Signature: _______________________________________________

Date: _______________________________________________

Representative's Signature (if applicable): _______________________________________________

Date: _______________________________________________

SUBMISSION INSTRUCTIONS

EFFECTIVE DATE NOTE: To preserve your effective date, file within one year of the prior decision. Filing more than one year after the decision may result in a new effective date.

Submit to:

Online: www.va.gov

Mail:
Department of Veterans Affairs
Claims Intake Center
PO Box 4444
Janesville, WI 53547-4444

Fax: 1-844-531-7818

In Person: Local VA Regional Office

IMPORTANT LEGAL REFERENCES

• 38 USC § 5108 - Reopening claims based on new and material evidence
• 38 USC § 5103A - Duty to assist claimants
• 38 CFR § 3.156 - New and material evidence
• 38 CFR § 3.2501 - Supplemental claims
• 38 CFR § 3.114 - Effective dates for liberalizing laws
• 38 CFR § 3.320 - PACT Act toxic exposure presumptions
• 38 CFR § 3.400 - General effective date rules

SUPPLEMENTAL CLAIM VS. OTHER OPTIONS

This template is designed to assist in preparing a VA Supplemental Claim. Individual circumstances vary, and this document should be reviewed by an accredited representative before submission.