Section I: Veteran's information
Items 1 to 9: the Veteran's name, Social Security number, whether a VA claim was ever filed and the VA file number, date of birth, service number, mailing address, phone and email.
21-0966
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or D.I.C. (VA Form 21-0966)
- Agency
- VA
- Revision
- May 2026
- Fillable fields
- 49
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21-0966: Intent to File for Compensation, Pension, Survivors Pension or DIC
VA Form 21-0966 is the U.S. Department of Veterans Affairs form for telling VA that you intend to file a claim for one or more general benefits: compensation, pension, or survivors pension and/or Dependency and Indemnity Compensation (DIC). VA's form page says to use it if you are still gathering information to support your claim and want to start the filing process.
The form is not a claim. Its declaration says a complete application for each general benefit still has to be filed. It also says that if VA receives a completed application for the selected benefit within one year of receiving this form, the application is considered filed as of the date VA received the intent to file.
The form is two pages. VA's page says an intent to file can also be submitted online. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21-0966
Section II: claimant's information
Items 10 to 18, only if the claimant is not the Veteran: name, Social Security number, VA file number, relationship to the Veteran, date of birth, mailing address, phone and email.
Section III: general benefit election
Item 19 has boxes for compensation, pension, and survivors pension and/or DIC. The form says VA may not be able to use it to establish an effective date if no benefit is selected.
Section IV: declaration and signature
The declaration acknowledges that the form is not a claim and that a complete application follows. Item 20 is the required signature, Item 21 the date and Item 22 a representative's name.
Mailing address and notices
Page 2 also holds the Evidence Intake Center mailing address, the penalty statement, the Privacy Act notice and the respondent burden of about 5 minutes.
How to file VA Form 21-0966
- 1
Fill in the Veteran's details
Complete Section I. The form asks you to complete as much as possible, since VA cannot process it if it cannot identify the claimant or the Veteran.
- 2
Add the claimant, if different
Complete Section II only if the person filing is not the Veteran.
- 3
Check one or more benefits
In Item 19, check each general benefit you intend to file for. The form says one form can list more than one benefit, or a separate form can be filed for each.
- 4
Sign and date it
Sign Item 20 and date Item 21. If an attorney, agent or Veterans service organization helps, their name goes in Item 22.
- 5
Send it to VA
Mail it to the Evidence Intake Center in Janesville, Wisconsin, or submit an intent to file online through VA's form page.
- 6
File the full application
The form says VA will give you the appropriate application for the benefit you selected, and that a completed application received within one year counts as filed on the date VA received this form.
Why fill Form 21-0966 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and what happens next
By mail
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
Online
VA's form page says you can submit your intent to file online instead of the paper form. It also says that if you file your disability claim online, you don't need to submit a paper Intent to File form.
The one-year window
The form says a completed application for the selected benefit received within one year is considered filed as of the date VA received this form. Only the first completed application for each selected benefit counts this way.
Questions
The form points to Ask VA at ask.va.gov and the toll-free number 1-800-827-1000 (TTY: 711).
Related forms
21-526EZ
Application for Disability Compensation and Related Compensation Benefits
345 fields, 15 pages
21P-527EZ
Application for Veterans Pension
477 fields, 17 pages
21-22
Appointment of Veterans Service Organization as Claimant’s Representative
63 fields, 4 pages
21-4138
Statement in Support of Claim (VA Form 21-4138)
33 fields, 2 pages
Who uses VA Form 21-0966?
The form has a section for the Veteran and a second one for the claimant when that is someone else.
Official sources and the blank
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Questions about Form 21-0966
Is VA Form 21-0966 a claim for benefits?
No. The declaration on the form says it is not a claim for benefits, and that a complete application for each general benefit is filed with VA before VA processes the claim.
How long after filing it do I have to send the full application?
The form says that if VA receives a completed application for the selected benefit within one year of receiving the intent to file, the application is considered filed as of the date VA received this form.
Can one form cover more than one benefit?
Yes. The form says you may indicate your intent to file for more than one general benefit on one form, or submit a separate VA Form 21-0966 for each.
Can I submit an intent to file online?
Yes. VA's form page says you can submit your intent to file online instead of sending the paper form, and that a disability claim filed online does not need a paper Intent to File form.
Who else can complete the form?
Item 14 lists relationships such as spouse, child, fiduciary, alternate signer and third party. The form says a VSO, attorney or agent may complete it only if a valid power of attorney has been completed.
Where do I mail VA Form 21-0966?
The form lists Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.