VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC
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JustFill helps you fill out VA Form 21-0966 — it does NOT submit the form to VA, set your effective date, or award any benefit. You mail or deliver the completed form to VA yourself, or submit your intent to file directly on VA.gov.JustFill is not affiliated with U.S. Department of Veterans Affairs (VA). This is an independent third-party tool to help you complete VA Form 21-0966. Always download the current blank form from the official source and verify your completed copy before signing or submitting. Official VA Form 21-0966 from U.S. Department of Veterans Affairs (VA)
VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC, notifies the Department of Veterans Affairs that you plan to apply for benefits, preserving your effective date for up to one year while you gather evidence. The veteran, surviving dependent, or authorized representative completes and signs it. JustFill fills the 21-0966 PDF online free — auto-detected fields, type or dictate, download.
VA Form 21-0966 is the Department of Veterans Affairs form that tells VA you intend to file a claim for disability compensation, Veterans Pension, or — for surviving dependents — Survivors Pension and/or Dependency and Indemnity Compensation (DIC) before your full application is ready. Submitting it preserves the date VA receives the form: if VA gets your completed application for the same benefit within one year, the claim is treated as filed on the intent-to-file date, which can mean months of retroactive payments. The current February 2023 revision (OMB Control No. 2900-0826) is a short two-page form with four sections — veteran identification, claimant identification (only when the claimant is not the veteran), general benefit election, and the declaration of intent with signature. JustFill auto-detects every box on the 21-0966 PDF so you can fill VA Form 21-0966 online free — type or dictate your answers in the browser and download the completed form, no Adobe needed.
The official February 2023 VA Form 21-0966 PDF is free to download from VA.gov and is in the public domain. Print it and mail it to the VA Evidence Intake Center, or open the same PDF in JustFill to type your answers on screen — VA never charges for submitting an intent to file.
Get the official VA Form 21-0966 PDF from U.S. Department of Veterans Affairs (VA)What each section of VA Form 21-0966 asks for. JustFill’s AI will detect these fields automatically when you upload the PDF — review the breakdown below so you know what to enter.
Veteran's name, Social Security Number, whether you have ever filed a VA claim, VA file number (if any), date of birth, and veteran's service number.
Mailing address, telephone number (with an international phone option), and e-mail address, plus a checkbox agreeing to receive electronic correspondence from VA.
Completed ONLY when the claimant is not the veteran: claimant's name, SSN, whether the claimant has ever filed a VA claim, VA file number, relationship to the veteran (spouse, child, fiduciary, Veteran Service Officer, alternate signer, third party, or other), date of birth, address, phone, and email.
Check every general benefit you intend to claim: Compensation, Pension, or — only if you are a surviving dependent — Survivors Pension and/or DIC. The form warns VA may not be able to establish an effective date if nothing is checked.
Required signature of the veteran, claimant, or authorized agent, plus the date signed. You acknowledge this is not a claim and that the full application must reach VA within one year.
Printed name of the representative completing the form; only valid when a power of attorney has been completed with VA.
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VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits
Statement in Support of Claim
VA Form 10-10EZ, Application for Health Benefits
Official source: VA Form 21-0966 on U.S. Department of Veterans Affairs (VA)’s website
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