We have included with this letter: 1. Explanation of Payment 2. Additional Benefits 3. Rating Decision 4. Where to Send Written Correspondence 5. VA Form 4107 6. VA Form 21-0958 Contact information: Web: www.vets.gov Phone: 1-800-827-1000 TDD: 711 To send questions online: visit https://iris.custhelp.com/ Social Media: Twitter: @VAVetBenefits Facebook: www.facebook.com/ VeteransBenefits Your representative: You appointed AMERICAN LEGION as your accredited representative. They have also received a copy of this letter. They can help you with any questions you have about your claim. If you or someone you know is in crisis, call the Veterans Crisis Line at 1-800-273-8255 and press 1. February 4, 2019 LAWRENCE PAUL WIDIKOWSKI 11 COOPER ST DANVILLE WV 25053 We made a decision on your VA benefits. Dear Lawrence Widikowski, This letter will guide you through the information you should know and steps you may take now that VA has made a decision about your benefits. Your Benefit Information: l Basic eligibility to Dependents' Educational Assistance is established from July 2, 2018. l Service connection for chronic obstructive pulmonary disease (COPD) is denied. l Service connection for hypertensive heart disease with sick sinus syndrome (also claimed as heart conditions) is granted with an evaluation of 100 percent effective July 2, 2018. l Service connection for scar anterior left upper chest is granted with an evaluation of 0 percent effective July 2, 2018. Your combined rating evaluation is 100%. How VA Combines Percentages If you have more than one condition, VA will combine percentages to determine your overall disability rating. The percentages assigned for each of your conditions may not always add up to your combined rating evaluation. The following website has additional information about how VA combines percentages: http://www.benefits.va.gov/compensation/rates-index.asp#howcalc. See Rating Decision to find out why we made this decision. Your dependents may be eligible for Dependents’ Educational Assistance (Chapter 35). For more information on this program, please visit the following web site: https://www.vets.gov/education/gi-

bill/survivors-dependent-assistance/ or call 1-888-GIBILL-1 (1-888-442-4551). Your monthly entitlement amount is shown below: Monthly Entitlement Amount Payment Start Date Reason $2,973.86 Aug 1, 2018 Original Award $3,057.13 Dec 1, 2018 Cost of Living Adjustment We are currently paying you as a single Veteran with no dependents. If payments are due, you should receive your first payment, if not already in receipt of payments, within 7-10 days of this notice. See Explanation of Payment for more details about your payment. Your payment will be directed to the financial institution and account number that you specified. To confirm when your payment was deposited, please contact your financial institution. If this account is no longer open, please notify us immediately. Evidence Considered In making our decision, in addition to the evidence listed in the Rating Decision, we considered the following evidence: l Please see enclosed rating decision narrative for evidence considered. Please Take Action: Accept, Appeal, and/or Ask for Help about Other Choices If you disagree with our decision: This decision notice explains why we made this decision about your benefits. If you disagree with the decision and would like to appeal it, you must complete and return a Notice of Disagreement, VA Form 21-0958, by February 4, 2020, one year from the date of this notice. File Number: 200469795 WIDIKOWSKI, LAWRENCE PAUL Page 2

The enclosed VA Form 4107 explains your right to appeal our decision. Your accredited representative can help you decide your next step. Your appointed accredited representative, AMERICAN LEGION, can help you with any questions you have about your claim. You can visit https://www.vets.gov/disability-benefits/claims-appeal/ to learn more about how the appeals process works. If you agree with our decision: There is no need to do anything other than ensure that if your banking and contact information changes, that you promptly notify us so there is no disruption to your benefit. Thank you for your service, Regional Office Director cc: AMERICAN LEGION File Number: 200469795 WIDIKOWSKI, LAWRENCE PAUL Page 3

Explanation of Payment We are currently paying you as a single Veteran with no dependents. Your combined evaluation is 30 percent or more disabling; therefore, you may be eligible for additional benefits based on dependency. We may be able to pay you retroactive benefits for your dependents if you submit your dependency claim within a year from the date of this letter. If you wish to notify us of your dependents, please do so through eBenefits, an electronic resource in a self-service environment. Use of these resources often helps us serve you faster! Just visit www.eBenefits.va.gov to enroll and submit your dependency information. Please Take Action: What Things Affect Your Right to Payment? Please notify VA immediately if there is a change in any condition affecting your right to continued payments. If you don’t notify us of these changes immediately, you may have to return any overpayments. Those changes include: Evidence received shows a change is warranted. Military Pay or Worker's Compensation: Your payments may be affected by the following, which you must bring to our attention: l Reentrance into active military or naval service. l Receipt of armed forces service retirement pay, unless your retirement pay has already been reduced because of award of disability compensation. l Receipt of benefits from the Office of Federal Employees Compensation. l Receipt of active duty or drill pay as a reservist or member of the National Guard. Dependents: If you have a disability rating of 30 percent or more, you must advise VA of any change with your spouse or children. Hospitalization: If your award includes Aid and Attendance benefits, we may reduce this additional allowance if you are admitted to a hospital, nursing home, or domiciliary care at VA expense. Incarceration: Benefits will be reduced if you are incarcerated in a federal, state, or local penal institution for more than 60 days for conviction of a felony. Lack of Cooperation: We may stop monthly payments if you: l fail to submit evidence we requested, l fail to attend a VA examination when requested, or l Submit false or fraudulent evidence to VA, or cause false or fraudulent evidence to be submitted to VA. Fraud/Lying to Government: The law provides severe penalties, which include fines, imprisonment, or both, for the fraudulent acceptance of any payment to which you are not entitled. We may verify information you submit through computer-matching programs with File Number: 200469795 WIDIKOWSKI, LAWRENCE PAUL Page 5

Evidence received shows a change is warranted. other agencies. Additional Benefits Education, Training, and Student Loans: l Education loans : For more information, please call 1-888-GIBILL-1 (1-888-442-4551) or visit www.vets.gov/education . l Veterans with student loans : For more information, please call 1-888-303-7818 or visit www.disabilitydischarge.com/ . l Job training and employment : For more information, please call 1-800-827-1000 or visit www.vba.va.gov/bln/vre/ . Medical Care and Treatment: l Mental Health Counseling: For more information, please visit www.myhealth.va.gov/mhv- portal-web/ . l Blind Rehabilitation: For more information, please visit www.va.gov/blindrehab/ . l Change in Compensation Benefits : For more information, please call 1-877-222-VETS or visit www.va.gov/healtheligibility . l Clothing Allowance : For more information, please call 1-800-827-1000 or visit www.vets.gov/disability-benefits/conditions/special-claims/clothing/ . l VA Medical Care : Present a copy of this notification letter to the Patient Registration/Eligibility Section at your nearest VA Medical Center www.vets.gov/facility- locator/ . l Dental Benefits : For more information, please contact your nearest VA Medical Center or outpatient clinic www.vets.gov/facility-locator/ . l Spouse or child health care : For more information, please call 1-800-733-8387 or visit www.va.gov/purchasedcare/programs/dependents/champva/ . Home Adaptations/Loans, Automobile Benefits, and Life Insurance: l Loans: For more information, please visit www.benefits.va.gov/homeloans/ . l Home upgrade due to disability : For more information, please visit File Number: 200469795 WIDIKOWSKI, LAWRENCE PAUL Page 6

www.benefits.va.gov/homeloans/adaptedhousing.asp . l Car upgrade due to disability : For more information, please call 1-800-827-1000 or visit www.vets.gov/disability-benefits/conditions/special-claims/automobile/ . l Government life insurance premiums : For more information, please call 1-800-669-8477 or visit www.benefits.va.gov/insurance . Armed Forces Commissary and Exchange: l Armed Forces Commissary and Exchange : For more information, please visit www.ebenefits.va.gov to locate your Regional Benefit Office, please visit www.vets.gov/facility-locator/ . Payment for Travel: l Payment for Travel : You may be eligible for reimbursement for beneficial travel mileage for previous VA medical appointments because of your newly granted service-connected conditions. You must make a request for such reimbursement within 30 days of this letter by contacting the Enrollment office at your Medical Center and providing a copy of this letter. State Benefits: l State Benefits: For more information, please visit www.va.gov/statedva.htm . Social Security Administration (SSA) Benefits: l Social Security Administration (SSA) Benefits : For more information about Social Security benefits, please call SSA at 1-800-772-1213 (Hearing Impaired TTY line 1-800-325-0778) or visit www.ssa.gov . File Number: 200469795 WIDIKOWSKI, LAWRENCE PAUL Page 7

DEPARTMENT OF VETERANS AFFAIRS Veterans Benefits Administration Regional Office LAWRENCE WIDIKOWSKI VA File Number 200 46 9795 Represented By: AMERICAN LEGION Rating Decision 02/01/2019 INTRODUCTION The records reflect that you are a veteran of the Peacetime and Vietnam Era. You served in the Navy from October 9, 1974, to August 26, 1976. You filed an original disability claim that was received on July 2, 2018. Based on a review of the evidence listed below, we have made the following decision(s) on your claim. DECISION 1. Service connection for hypertensive heart disease with sick sinus syndrome (also claimed as heart conditions) is granted with an evaluation of 100 percent effective July 2, 2018. 2. Service connection for scar anterior left upper chest is granted with an evaluation of 0 percent effective July 2, 2018. 3. Basic eligibility to Dependents' Educational Assistance is established from July 2, 2018. 4. Service connection for chronic obstructive pulmonary disease (COPD) is denied.

EVIDENCE l Correspondence received December 14, 2018 l Private Treatment Records received, December 14, 2018 l Disability Benefit Questionnaire Medical Opinions dated, January 16, 2019 l Disability Benefit Questionnaires dated, January 16, 2019 REASONS FOR DECISION 1. Service connection for hypertensive heart disease with sick sinus syndrome (also claimed as heart conditions). Service connection for hypertensive heart disease with sick sinus syndrome (also claimed as heart conditions) has been established as directly related to military service. The effective date of this grant is July 2, 2018. Service connection has been established from the day VA received your claim. When a claim of service connection is received more than one year after discharge from active duty, the effective date is the date VA received the claim. An evaluation of 100 percent is assigned from July 2, 2018. We have assigned a 100 percent evaluation for your heart conditions based on: • Workload of three METs or less results in dyspnea, fatigue, angina, dizziness, or syncope Additional symptom(s) include: • Evidence of cardiac hypertrophy on echocardiogram • Left ventricular dysfunction with an ejection fraction of more than 50 percent This is the highest schedular evaluation allowed under the law for hypertensive heart disease. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 2. Service connection for scar anterior left upper chest. Service connection for scar anterior left upper chest has been established as directly related to military service. A noncompensable evaluation is assigned from July 2, 2018, the date your claim was received. We have assigned a 0 percent evaluation for your scar anterior left upper chest based on: • Other areas of disfigurement not considered under another appropriate diagnostic code LAWRENCE WIDIKOWSKI 200 46 9795 2 of 4

Additional symptom(s) include: • Scar 1 Location: Anterior trunk • Scar 1 type: scar • cm Note: In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. {38 CFR §4.31} Your first scar/area has a length of 3 cm and a width of 0.5 cm for a total area of 1.5 sq. cm. An additional, separate compensable evaluation under Diagnostic Code 7804 is not warranted unless there is at least one scar that is painful or unstable. This is the highest schedular evaluation allowed under the law for scars, other (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804. 3. Eligibility to Dependents' Educational Assistance under 38 U.S.C. Chapter 35. Eligibility to Dependents' Educational Assistance is derived from a veteran who was discharged under other than dishonorable conditions; and, has a permanent and total service-connected disability; or a permanent and total disability was in existence at the time of death; or the veteran died as a result of a service-connected disability. Also, eligibility exists for a serviceperson who died in service. Finally, eligibility can be derived from a service member who, as a member of the armed forces on active duty, has been listed for more than 90 days as: missing in action; captured in line of duty by a hostile force; or forcibly detained or interned in line of duty by a foreign government or power. Basic eligibility to Dependents' Education Assistance is granted as the evidence shows you have a total service-connected disability, permanent in nature. Basic eligibility to Dependents' Educational Assistance is established from July 2, 2018, the date your claim was received. 4. Service connection for chronic obstructive pulmonary disease (COPD). Service connection may be granted for a disability which began in military service or was caused by some event or experience in service. VA examiner reported chronic obstructive pulmonary disease (COPD) was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. Rationale: COPD/Emphysema are normally conditions that develop over time. It is not likely your respirations/oxygen level would be severe enough to cause your symptoms of fatigue, dizziness, unconsciousness and syncope while you were on active duty without being detected. It is less likely than not that your COPD is related to your active duty symptoms of dizziness, unconsciousness and syncope. Service connection for chronic obstructive pulmonary disease (COPD) is denied. LAWRENCE WIDIKOWSKI 200 46 9795 3 of 4

REFERENCES: Title 38 of the Code of Federal Regulations, Pensions, Bonuses and Veterans' Relief contains the regulations of the Department of Veterans Affairs which govern entitlement to all veteran benefits. For additional information regarding applicable laws and regulations, please consult your local library, or visit us at our website, www.va.gov . LAWRENCE WIDIKOWSKI 200 46 9795 4 of 4

Where to Send Your Written Correspondence In order to properly determine where to send your written correspondence, please first identify your benefit type (Compensation, Veterans Pension, or Survivor Benefits); then, locate the corresponding address based on your location of residence. For correspondence relating to all Compensation claims: Location of Residence Address All United States and Foreign Locations * Note : For foreign Veterans Pension and Survivor Benefits please refer to the below addresses. Department Of Veterans Affairs Evidence Intake Center P.O. Box 4444 Janesville, WI, 53547-4444 Or fax your information to: Toll Free: 844-531-7818 Local: 248-524-4260 For correspondence relating to all Veterans Pension and Survivor Benefit claims : Location of Residence Address Alabama Arkansas Illinois Indiana Kentucky Louisiana Michigan Mississippi Missouri Ohio Tennessee Wisconsin Department Of Veterans Affairs Claims Intake Center Attention: Milwaukee Pension Center P.O. Box 5192 Janesville, WI 53547-5192 Or fax your information to: Toll Free: (844) 655-1604 Alaska Arizona California Colorado Hawaii Idaho Iowa Kansas Minnesota Montana Nebraska Nevada New Mexico North Dakota Oklahoma Oregon South Dakota Texas Utah Washington Wyoming Mexico Central America South America Caribbean Department Of Veterans Affairs Claims Intake Center Attention: St. Paul Pension Center P.O. Box 5365 Janesville, WI 53547-5365 Or fax your information to: Toll Free: (844) 655-1604 Connecticut Delaware Florida Georgia Maine Maryland Massachusetts New Hampshire New Jersey New York North Carolina Pennsylvania Rhode Island South Carolina Vermont Virginia West Virginia District of Columbia Puerto Rico Canada Department Of Veterans Affairs Claims Intake Center Attention: Philadelphia Pension Center P.O. Box 5206 Janesville, WI 53547-5206 Or fax your information to: Toll Free: (844) 655-1604 Countries outside of North, Central or South America

YOUR RIGHTS TO APPEAL OUR DECISION After careful and compassionate consideration, a decision has been reached on your claim. If we were not able to grant some or all of the VA benefits you asked for, this form will explain what you can do if you disagree with our decision. If you do not agree with our decision, you may: Start an appeal by submitting a Notice of Disagreement. Give us evidence we do not already have that may lead us to change our decision. This form will tell you how to appeal and how to send us more evidence. You can do either one or both of these things. H OW C AN I A PPEAL THE D ECISION? How do I start my appeal? To begin your appeal, you must submit VA Form 21-0958, "Notice of Disagreement," if that form was provided to you in connection with our decision. If we denied more than one claim for a benefit (for example, if you claimed compensation for three disabilities and we denied two of them), please tell us in Part IV of VA Form 21-0958 each of the claims you are appealing. A filed VA Form 21-0958 is considered your Notice of Disagreement. If you did not receive VA Form 21-0958 in connection with our decision, then write us a letter telling us you disagree with our decision or enter your disagreement on VA Form 21-0958 in questions 11 or 12A. If you did not receive VA Form 21-0958 in connection with our decision, then either your statement or VA Form 21-0958 is considered your Notice of Disagreement. Send your Notice of Disagreement to the address included on our decision notice letter. How long do I have to start my appeal? You have one year to start an appeal of our decision. Your Notice of Disagreement must be postmarked (or received by us) within one year from the date of our letter denying you the benefit. In most cases, you cannot appeal a decision after this one-year period has ended. What happens if I do not start my appeal on time? If you do not start your appeal on time, our decision will become final. Once our decision is final, you cannot get the VA benefit we denied unless you either: Show that we were clearly wrong to deny the benefit or Send us new evidence that relates to the reason we denied your claim. What happens after VA receives my Notice of Disagreement? We will either grant your claim or send you a Statement of the Case. A Statement of the Case describes the facts, laws, regulations, and reasons that we used to make our decision. We will also send you a VA Form 9, "Appeal to Board of Veterans' Appeals," with the Statement of the Case. If you want to continue your appeal to the Board of Veterans' Appeals (Board) after receiving a Statement of the Case, you must complete and return the VA Form 9 within one year from the date of our letter denying you the benefit or within 60 days from the date that we mailed the Statement of the Case to you, whichever is later . If you decide to complete an appeal by filing a VA Form 9, you have the option to request a Board hearing. Hearings often increase wait time for a Board decision. It is not necessary for you to have a hearing for the Board to decide your appeal. It is your choice. Where can I find out more about the VA appeals process? You can find a "plain language" pamphlet called "How Do I Appeal," on the Internet at: http://www.bva.va.gov/How_Do_I_Appeal.asp . You can find the formal rules for the VA appeals process in title 38, Code of Federal Regulations, Part 20. You can find the complete Code of Federal Regulations on the Internet at: http://www.ecfr.gov . A printed copy of the Code of Federal Regulations may be available at your local law library. VA FORM JUN 2016 4107 (Please continue reading on page 2) Can I get someone to help me with my appeal? Yes. You can have a Veterans Service Organization representative, an attorney-at-law, or an "agent" help you with your appeal. You are not required to have someone represent you. It is your choice. Y OUR R IGHT TO R EPRESENTATION Representatives who work for accredited Veterans Service Organizations know how to prepare and present claims and will represent you. You can find a listing of these organizations on the Internet at: http://www.va.gov/vso .

A private attorney or an "agent" can also represent you. VA only recognizes attorneys who are licensed to practice in the United States or in one of its territories or possessions. Your local bar association may be able to refer you to an attorney with experience in veterans' law. An agent is a person who is not a lawyer, but who VA recognizes as being knowledgeable about veterans' law. Contact us if you would like to know if there is a VA accredited agent in your area. Do I have to pay someone to help me with my appeal? It depends on who helps you. The following explains the differences. Veterans Service Organizations will represent you for free. Attorneys or agents can charge you for helping you under some circumstances. Paying their fees for helping you with your appeal is your responsibility. If you do hire an attorney or agent to represent you, a copy of any fee agreement must be sent to VA. The fee agreement must clearly specify if VA is to pay the attorney or agent directly out of past-due benefits. See 38 C.F.R. § 14.636(g)(2). If the fee agreement provides for the direct payment of fees out of past-due benefits, a copy of the direct- pay fee agreement must be filed with us at the address included on our decision notice letter within 30 days of its execution. A copy of any fee agreement that is not a direct-pay fee agreement must be filed with the Office of the General Counsel within 30 days of its execution by mailing the copy to the following address: Office of the General Counsel (022D), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420. See 38 C.F.R. § 14.636(g)(3). G IVING VA A DDITIONAL EVIDENCE You can send us more evidence to support a claim whether or not you choose to appeal . NOTE: Please direct all new evidence to the address included on our decision notice letter. You should not send evidence directly to the Board at this time. You should only send evidence to the Board if you decide to complete an appeal and, then, you should only send evidence to the Board after you receive written notice from the Board that they received your appeal. If you have more evidence to support a claim, it is in your best interest to give us that evidence as soon as you can. We will consider your evidence and let you know whether it changes our decision. Please keep in mind that we can only consider new evidence that: (1) we have not already seen and (2) relates to your claim. You may give us this evidence either in writing or at a personal hearing with your local VA office. In writing. To support your claim, you may send documents and written statements to us at the address included on our decision notice letter. Tell us in a letter how these documents and statements should change our earlier decision. At a personal hearing. You may request a hearing with an employee at your local VA office at any time, whether or not you choose to appeal. We do not require you to have a local hearing. It is your choice. At this hearing, you may speak, bring witnesses to speak on your behalf, and hand us written evidence. If you want a local hearing, send us a letter asking for a local hearing. Use the address included on our decision notice letter. We will then: Arrange a time and place for the hearing Provide a room for the hearing Assign someone to hear your evidence Make a written record of the hearing WHAT H APPENS A FTER I G IVE VA E VIDENCE? We will review any new evidence, including the record of the local hearing, if you choose to have one, together with the evidence we already have. We will then decide if we can grant your claim. If we cannot grant your claim and you complete an appeal, we will send the new evidence and the record of any local hearing to the Board. BACK OF VA FORM 4107, JUN 2016 SUPERSEDES VA FORM 4107, JUN 2015, WHICH WILL NOT BE USED.

VA FORM SEP 2015 21-0958 INFORMATION AND INSTRUCTIONS FOR COMPLETING NOTICE OF DISAGREEMENT (NOD) IMPORTANT: Please read the information below carefully to help you complete this form quickly and accurately. Some parts of the form also contain notes or specific instructions for completing that part. The use of this form is mandatory to initiate an appeal from the decision on disability compensation claims you received . This form has several key components, which, when filled out completely and accurately, will decrease the amount of time it takes to process your NOD. FREQUENTLY ASKED QUESTIONS How do I use this standard Notice of Disagreement (NOD) form? You must use this form if you wish to indicate that you disagree with a decision you received regarding your claim for disability compensation. Examples of these decisions may include entitlement to service connection, percentage of evaluation assigned, and effective date among other things. This form is the only way that you can initiate an appeal from a decision on your claim for disability compensation. Should I fill out this form? You must fill out this form if you disagree with a decision issued by the VA regional office (RO) about your disability compensation claim. This includes an initial decision, a decision for an increased rating, or any other decision with which you disagree. Only those issues that you list on this NOD will be considered on appeal. For those issues you do not list on this NOD, you will still have one year from the date of the decision notification letter to file an appeal for those issues. Where can I get help? You can ask the Department of Veterans Affairs (VA) to help you fill out the form by contacting us at 1-800-827-1000. Before you contact us, please make sure you gather the necessary information and materials, and complete as much of the form as you can. You can also contact your representative, if applicable, for assistance with completing this form. If you do not already have a representative, you can find a list of approved Veterans Service Organizations at www.va.gov/vso . You can be represented by a Veterans Service Organization representative, an attorney-at-law, or "agent". Contact your local RO for assistance with appointing a representative or visit www.ebenefits.va.gov . What should I do when I have finished my NOD? You should provide your signature in Item 13A and the date signed in Item 13B. Be sure to sign every form you fill out before you send it to us. If you don't sign the form, VA will return it for you to sign, and it will take longer to process. Attach any materials that support and explain your NOD. Mail your NOD to the address included on the VA decision notice letter or take your NOD to your local RO. Do I need to keep a copy of this NOD form? It is important that you keep a copy of all completed forms and materials you give to VA. What constitutes a complete NOD form? Generally, VA will consider your NOD "complete" if the following information is provided on the form: (1) Part I - Information to identify the claimant such as name, Social Security Number, or VA claim number . Please note that it would assist VA if you provide all the personal information in Part I. However, if you provide certain information specific to the claimant such as the claimant's last name and Social Security Number or VA file number, VA will be able to identify the claimant in our system and would not necessarily consider this NOD incomplete if other information in Part I, such as the claimant's address and telephone number, is excluded. (2) Part IV - Information to identify the specific nature of the disagreement. Please list the issues or conditions for which you seek appellate review in Item 11 of Part IV. At a minimum, please indicate the specific issue of disagreement in Item 11A such as "right knee disability" or "Post Traumatic Stress Disorder (PTSD)" and indicate the area of disagreement in Item 11B by checking the appropriate box. If you disagree with an evaluation of a disability, you may tell us what percentage evaluation you seek in Item 11C; however, you are not required to indicate the percentage of evaluation sought in Item 11C in order to complete this form. (3) Part V - Claimant's signature. Please be sure to sign the NOD, certifying that the statements on the form are true and correct to the best of the claimant's knowledge and belief. IMPORTANT : If you do not provide the above information on this NOD, VA will consider your form incomplete and will request clarification from you. You must respond to this request for clarification either 60 days from the date of VA's request for clarification or one year from the date of mailing of the notice of decision of the RO, whichever is later. If you do not provide VA with a completed form within that time frame, the decision will become final, and you will have to file a new claim. Page 1

VA FORM 21-0958, SEP 2015 SPECIFIC INSTRUCTIONS FOR THE NOD Part I - Personal Information Please provide all personal contact information. Part II - Telephone Contact Why is VA asking to contact me by telephone? The purpose of the optional telephone contact is to help process your NOD faster by requesting clarification of any ambiguous information on the form. If you indicate you wish to be contacted by telephone, VA may make up to two attempts to call you at the telephone number provided during the time slot you select. It is important to make sure you select a time period you will be available to speak with a RO representative by telephone. Part III - Election of Decision Review Officer (DRO) Review or Traditional Appellate Review How does the DRO Review Process work? A DRO is a senior technical expert who did not participate in the decision being reviewed who is responsible for holding post-decisional hearings, if requested, and processing appeals. The DRO will conduct a new and complete review of your claim, without deference to the original decision. The DRO will determine if there is additional evidence necessary to resolve the appeal, may ask you to participate in an informal conference, and/or may pursue additional evidence. The DRO may issue a new decision that changes the original decision by the RO. How does the Traditional Appellate Review Process work? A VA staff member will examine your file and any new evidence that you submit with or after your NOD. The reviewer may change the original decision based on new evidence or upon a finding of clear and unmistakable error in that decision. How do I complete this section? If you wish to elect the DRO Review Process, please check the "Decision Review Officer (DRO) Review Process" box in Item 9 . If you wish to continue in the Traditional Appellate Review Process, please check the "Traditional Appellate Review Process" box in Item 9. Please note that failure to complete this section will not render the form incomplete. Part IV - Specific Issues of Disagreement What date do I enter in the Notification/Decision Letter Date? You should enter the date stamped on the notification or decision letter you received that you disagree with in Item 10. Please do not enter today's date in this field. If you need help identifying the date of the notification or decision you disagree with, contact us at 1-800-827-1000. How do I complete this section? The purpose of this section is for you to individually identify each area of disagreement that you have with the VA decision notification letter. Please list only the issues or disabilities with which you disagree. Only those issues that you list on this NOD will be considered on appeal. For those issues you do not list on this NOD, you will still have one year from the date of the decision notification letter to file an appeal for those issues. In the Specific Issue of Disagreement column in Item 11A, please individually identify in separate boxes each of the issues with which you disagree. For example, "left knee condition," "hearing loss," etc. In the "Area of Disagreement" column, Item 11B, please check the area with which you disagree. For example, if you disagree with the effective date that VA assigned for a particular benefit, check the "Effective Date of Award" option. If VA granted a benefit, but you disagree with the evaluation that we assigned, check the "Evaluation of Disability" option. If you were claiming service connection for an injury or disability that you believe to be the result of your military service, and VA denied that claim, please check the "Service Connection" option. If you are disagreeing with our decision for reasons other than listed in the "Area of Disagreement" column, please check "Other" and specify your reason. If you disagree with a disability evaluation that we have assigned and believe that the evidence justifies a specific evaluation, please list the percentage that you believe the evidence to warrant in the "Percentage of Evaluation Sought If Known" column, Item 11C, within Part IV of the form. To assist, please refer to our decision notification letter where we indicate what the evidence must show for the evaluation we assigned as well as the next higher evaluation. Please note that this information is not required and that, even if you limit your appeal by indicating a specific percentage evaluation sought in Item 11C, evaluation levels above the percentage evaluation sought will be considered in cases where the evidence supports a higher evaluation. There is extra space provided for you in Item 12A, to explain why you feel VA incorrectly decided your claim, and to list any disagreements not covered by the form. Please utilize this space to briefly and clearly explain why you disagree with our decision. Part V - Certification and Signature Sign and date the NOD, certifying that the statements on the form are true to the best of your knowledge and belief. Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. Respondent Burden: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain . If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. Page 2

6. PREFERRED TELEPHONE NUMBER (Include Area Code) OMB Approved No. 2900-0791 Respondent Burden: 30 minutes Expiration Date: 09/30/2018 CLAIMANT'S PERSONAL INFORMATION PART II - TELEPHONE CONTACT PART I - PERSONAL INFORMATION NOTICE OF DISAGREEMENT A CLAIMANT OR HIS OR HER DULY APPOINTED REPRESENTATIVE MAY FILE NOTICE EXPRESSING THEIR DISSATISFACTION OR DISAGREEMENT WITH AN ADJUDICATIVE DETERMINATION BY THE VA REGIONAL OFFICE. A DESIRE TO CONTEST THE RESULT WILL CONSTITUTE A NOTICE OF DISAGREEMENT (NOD.) WHILE SPECIAL WORDING IS NOT REQUIRED, THE NOD MUST BE IN TERMS WHICH CAN BE REASONABLY CONSTRUED AS DISAGREEMENT WITH THAT DETERMINATION AND A DESIRE FOR APPELLATE REVIEW. (AUTHORITY: 38 U.S.C. 7105) TO FILE A VALID NOD, THERE IS A TIME LIMIT OF ONE YEAR FROM THE DATE VA MAILED THE NOTIFICATION OF THE DECISION TO THE CLAIMANT. FOR CONTESTED CLAIMS INCLUDING CLAIMS OF APPORTIONMENT, THIS TIME LIMIT IS 60 DAYS FROM THE DATE VA MAILED THE NOTIFICATION OF THE DECISION TO THE CLAIMANT. (DO NOT WRITE IN THIS SPACE) (VA DATE STAMP) C/CSS - 8. WOULD YOU LIKE TO RECEIVE A TELEPHONE CALL OR E-MAIL FROM A REPRESENTATIVE AT YOUR LOCAL REGIONAL OFFICE REGARDING YOUR NOD? (If you answered "Yes," VA will make up to two attempts to call you between 8:00 a.m. and 4:30 p.m. local time at the telephone number and time period you select below. Please select up to two time periods you are available to receive a phone call.) 8:00 a.m. - 10:00 a.m. 10:00 a.m. - 12:30 p.m. 12:30 p.m. - 2:00 p.m. 2:00 p.m. - 4:30 p.m. Phone number I can be reached at the above checked time: PART III - APPEAL PROCESS ELECTION 21-0958 VA FORM SEP 2015 1. VETERAN'S NAME (First, middle initial, last) 3. VA FILE NUMBER 2. VETERAN'S SOCIAL SECURITY NUMBER 4. CLAIMANT'S NAME (First, middle initial, last) 5. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country) 7. PREFERRED E-MAIL ADDRESS Page 3 9. SELECT ONE OF THE APPEALS PROCESSING METHODS BELOW (See Specific Instructions , Page 2 , Part III for additional information) Traditional Appellate Review Process Decision Review Officer (DRO) Review Process NOTE : You can either complete the form online or by hand. Please print information using blue or black ink, neatly, and legibly to help process the form. No. & Street Apt./Unit Number State/Province Country ZIP Code/Postal Code City YES NO SUPERSEDES VA FORM 21-0958, JAN 2015, WHICH WILL NOT BE USED.

Service Connection PART IV - SPECIFIC ISSUES OF DISAGREEMENT PENALTY: THE LAW PROVIDES SEVERE PENALTIES WHICH INCLUDE A FINE, IMPRISONMENT, OR BOTH, FOR THE WILLFUL SUBMISSION OF ANY STATEMENT OR EVIDENCE OF A MATERIAL FACT, KNOWING IT TO BE FALSE. 12A. IN THE SPACE BELOW, OR ON A SEPARATE PAGE, PLEASE EXPLAIN WHY YOU FEEL WE INCORRECTLY DECIDED YOUR CLAIM, AND LIST ANY DISAGREEMENT(S) NOT COVERED ABOVE: 12B. DID YOU ATTACH ADDITIONAL PAGES TO THIS NOD? (If so, how many?) PART V - CERTIFICATION AND SIGNATURE I CERTIFY THAT THE STATEMENTS ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. 13A. SIGNATURE 13B. DATE SIGNED VA FORM 21-0958, SEP 2015 Effective Date of Award Evaluation of Disability Other (Please specify below) ____________________________ 11. PLEASE LIST EACH SPECIFIC ISSUE OF DISAGREEMENT AND NOTE THE AREA OF DISAGREEMENT. IF YOU DISAGREE ON THE EVALUATION OF A DISABILITY, SPECIFY PERCENTAGE EVALUATION SOUGHT, IF KNOWN. PLEASE LIST ONLY ONE DISABILITY IN EACH BOX. YOU MAY ATTACH ADDITIONAL SHEETS IF NECESSARY. A. Specific Issue of Disagreement B. Area of Disagreement C. Percentage (%) Evaluation Sought (If known) 10. NOTIFICATION/DECISION LETTER DATE Service Connection Effective Date of Award Evaluation of Disability Other (Please specify below) ____________________________ Service Connection Effective Date of Award Evaluation of Disability Other (Please specify below) ____________________________ Service Connection Effective Date of Award Evaluation of Disability Other (Please specify below) ____________________________ Service Connection Effective Date of Award Evaluation of Disability Other (Please specify below) ____________________________ Page 4 VETERAN'S SSN YES NO