This form contains 69 fields organized into 22 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Claimant VA Claim Status
YES	Radiobutton	Check this box if the claimant has previously filed a VA claim.
NO	Radiobutton	Check this box if the claimant has not previously filed a VA claim.
Claimant's Date of Birth
Claimant's Date of Birth Month	Date	Enter the month of the claimant's birth. Max length: 2 characters
Claimant's Date of Birth Day	Date	Enter the day of the claimant's birth. Max length: 2 characters
Claimant's Date of Birth Year	Date	Enter the year of the claimant's birth. Max length: 4 characters
Claimant's E-mail Address
Claimant's Email Address	Text	Provide the email address of the claimant. Max length: 20 characters
Agree to Receive Electronic Correspondence	Text	Indicate if the claimant agrees to receive electronic correspondence from VA in regards to their claim. Max length: 20 characters
Agree to receive electronic correspondence	Checkbox	Check this box if you agree to receive electronic correspondence from the VA regarding your claim.
Claimant's Mailing Address
ZIP Code Extension	Text	Please enter the extension (last four digits) of the claimant's ZIP Code or Postal Code. Max length: 4 characters
ZIP Code	Text	Please enter the first part of the claimant's ZIP Code or Postal Code. Max length: 5 characters
Country	Text	Please enter the country of the claimant's mailing address. Max length: 2 characters
State/Province	Text	Please enter the state or province of the claimant's mailing address. Max length: 2 characters
City	Text	Please enter the city of the claimant's mailing address. Max length: 18 characters
Apartment/Unit Number	Text	Please enter the apartment or unit number of the claimant's mailing address. Max length: 5 characters
Street Address	Text	Please enter the street number and name of the claimant's mailing address. Max length: 30 characters
Claimant's Name
Claimant's Last Name	Text	Enter the claimant's last name. Max length: 18 characters
Claimant's Middle Initial	Text	Enter the claimant's middle initial. Max length: 1 characters
Claimant's First Name	Text	Enter the claimant's first name. Max length: 12 characters
Claimant's Social Security Number
Last Part of Claimant's Social Security Number	Text	Enter the last four digits of the claimant's social security number. Max length: 4 characters
Middle Part of Claimant's Social Security Number	Text	Enter the middle two digits of the claimant's social security number. Max length: 2 characters
First Part of Claimant's Social Security Number	Text	Enter the first three digits of the claimant's social security number. Max length: 3 characters
Claimant's Telephone Number
International Phone Number	Text	Enter the claimant's full international telephone number, including the country code if applicable.
Phone Number Last Digits	Text	Enter the four-digit last part of the claimant's domestic telephone number. Max length: 4 characters
Phone Number Middle Digits	Text	Enter the three-digit middle part of the claimant's domestic telephone number. Max length: 3 characters
Area Code	Text	Enter the three-digit area code of the claimant's domestic telephone number. Max length: 3 characters
Claimant's VA File Number
Claimant's VA File Number	Text	Provide the VA file number for the claimant. Fill only if 'YES' is 'Yes'. Max length: 9 characters Depends on: YES
Date Signed
Year Signed	Date	Enter the year the document was signed. Max length: 4 characters
Day Signed	Date	Enter the day the document was signed. Max length: 2 characters
Month Signed	Date	Enter the month the document was signed. Max length: 2 characters
General
	Signature
General Benefit Election
Pension	Checkbox	Check this box if you intend to file for a General Benefit of Pension.
Compensation	Checkbox	Check this box if you intend to file for a General Benefit of Compensation.
Survivors Pension and/or Dependency and Indemnity Compensation (DIC)	Checkbox	Check this box if you are a surviving dependent of the veteran and intend to file for Survivors Pension and/or Dependency and Indemnity Compensation (DIC). Fill only if 'Claimant's Relationship to Veteran' is 'Surviving Dependent' Depends on: Spouse, Child
Relationship to Veteran
Spouse	Radiobutton	Check this box if the claimant's relationship to the veteran is that of a spouse.
Child	Radiobutton	Check this box if the claimant's relationship to the veteran is that of a child.
Fiduciary	Radiobutton	Check this box if the claimant is acting as a fiduciary for the veteran.
Veteran Service Officer	Radiobutton	Check this box if the claimant is a Veteran Service Officer.
Alternate Signer	Radiobutton	Check this box if the claimant is an alternate signer for the veteran.
Third-Party	Radiobutton	Check this box if the claimant is a third-party representative for the veteran.
Other (Specify)	Radiobutton	Check this box if the claimant's relationship to the veteran is not covered by the other options and then specify the relationship in the provided field.
Other Relationship to Veteran	Text	Please specify your relationship to the veteran if it is not one of the predefined options. Fill only if 'Other (Specify)' is 'Yes'. Depends on: Other (Specify)
Veteran VA Claim Status
YES	Radiobutton	Check this box if you have previously filed a VA claim.
NO	Radiobutton	Check this box if you have never previously filed a VA claim.
Veteran's Date of Birth
Birth Month	Text	Please provide the veteran's birth month. Max length: 2 characters
Birth Day	Text	Please provide the veteran's birth day. Max length: 2 characters
Birth Year	Number	Please provide the veteran's birth year. Max length: 4 characters
Veteran's E-mail Address
Veteran's Alternate Email Address	Text	Provide an alternate email address for the veteran, if applicable. Max length: 20 characters
Veteran's Primary Email Address	Text	Provide the veteran's primary email address for correspondence. Max length: 20 characters
Agree to Receive Electronic Correspondence	Checkbox	Check this box if you agree to receive electronic correspondence from the VA regarding your claim.
Veteran's Mailing Address
Veteran's Street Address	Text	Provide the street number and street name of the veteran's mailing address. Max length: 30 characters
Veteran's Apartment/Unit Number	Text	Enter the apartment or unit number, if applicable, for the veteran's mailing address. Max length: 5 characters
Veteran's City	Text	Provide the city name for the veteran's mailing address. Max length: 18 characters
Veteran's State/Province	Text	Enter the state or province for the veteran's mailing address. Max length: 2 characters
Veteran's Country	Text	Provide the country name for the veteran's mailing address. Max length: 2 characters
Veteran's ZIP/Postal Code	Text	Enter the primary part of the ZIP code or postal code for the veteran's mailing address. Max length: 5 characters
Veteran's ZIP+4 Extension	Text	Provide the four-digit extension of the ZIP code for the veteran's mailing address. Max length: 4 characters
Veteran's Name
Veteran's Full Name	Text	Please provide the veteran's full name, including first name, middle initial, and last name. Max length: 12 characters
	Text	Max length: 18 characters
	Text	Max length: 1 characters
Veteran's Service Number
Veteran's Service Number	Text	Provide the veteran's service number. Max length: 9 characters
Veteran's Social Security Number
First 3 Digits of Social Security Number	Text	Please provide the first three digits of the veteran's Social Security Number. Max length: 3 characters
Middle 2 Digits of Social Security Number	Text	Please provide the middle two digits of the veteran's Social Security Number. Max length: 2 characters
Last 4 Digits of Social Security Number	Text	Please provide the last four digits of the veteran's Social Security Number. Max length: 4 characters
Veteran's Telephone Number
International Phone Number	Text	Enter the veteran's international phone number if applicable.
Telephone Number Line Number	Text	Enter the line number of the veteran's telephone number. Max length: 4 characters
Telephone Number Prefix	Text	Enter the prefix of the veteran's telephone number. Max length: 3 characters
Telephone Number Area Code	Text	Enter the area code of the veteran's telephone number. Max length: 3 characters
Veteran's VA File Number
VA File Number	Text	Provide the veteran's VA file number if applicable. Fill only if 'YES' is 'Yes'. Max length: 9 characters Depends on: YES
VSO Name
VSO Name	Text	Provide the full name of the Attorney, Agent, or Veterans Service Organization (VSO) completing this form. Fill only if 'A valid power of attorney has been completed' is 'Yes' Depends on: Veteran Service Officer

VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or DIC Instructions