VA Form 20-0995 Example: Supplemental Claim, Item by Item

VA Form 20-0995 asks VA to decide an issue again because you have new and relevant evidence. The current edition is dated May 2024. The two parts that matter most are Item 21, where you list each issue VA already decided and the date of its decision notice, and Section V, where you attach or identify the new evidence. This fictional example goes through the form in order, including the Item 23 notice box and the legacy-appeal opt-in language that many older examples leave out.

Fictional veteran Jordan Lee received a decision notice dated April 15, 2026 that denied service connection for a right ankle condition. Jordan now has an orthopedic report dated June 2, 2026 that VA has never seen, and wants VA to get records from a private physical therapy clinic. Never copy these invented facts onto a real form.

Item 1: Benefit type

Check one box only. Jordan checks Compensation. If you need reviews for two benefit types, such as compensation and pension, file a separate 20-0995 for each.

Sections I and II: Identification (Items 2 to 19)

Section I (Items 2 to 10) identifies the veteran: name, Social Security number, VA file number, date of birth, service number, insurance policy number if any, mailing address, phone and optional email. Jordan fills in the actual details from Jordan's records. The instructions say VA can identify you with the last name and Social Security or file number even if an address or phone is missing, but complete it anyway.

Section II (Items 11 to 19) is only for a claimant who is not the veteran, such as a surviving spouse, with that person's details and relationship to the veteran. Jordan skips it.

Section III: Homeless information (Items 20A to 20D)

Complete this only if you are homeless or at risk of becoming homeless; VA uses it to prioritize your request. Items 20C and 20D ask for a point of contact. Jordan checks No in 20A and moves on.

Section IV: Issues for the Supplemental Claim (Item 21)

Above the issue lines, Item 21 contains a legacy-appeal statement. If you are answering a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC) in the old appeals system, filing this form within 60 days of that SOC or SSOC moves the listed issues into the current review system, withdraws them and any hearing requests from the legacy system, and you cannot return. Jordan's decision is a current-system decision, so the statement does not apply.

Copy the issue as the decision notice words it, one line per issue. Only the issues you list are reviewed. For issues you leave off, the instructions say you still have one year from the decision notice to file and keep the earliest effective date. If you are filing within a year of a court decision, the instructions ask you to put the court decision's date in 21B and attach a copy.

Section V: New and relevant evidence (Items 22A to 22D)

"New" means VA has not seen it before, and "relevant" means it tends to prove or disprove something in the claim. Unless your Supplemental Claim is based on a change in law, the form is not complete without new and relevant evidence you submit or identify.

Item 22A asks where you were treated. Jordan checks Private health care provider and VA medical center(s) and community-based outpatient clinics. The form's note explains the difference: VA already has access to VA medical center, community clinic and military treatment facility records and needs no consent form, but for private provider records (other than VA-paid community care) or Vet Center records, VA needs VA Forms 21-4142 and 21-4142a.

The form says you do not need to give dates in 22C if treatment began in 2005 or later. Jordan attaches the June 2 orthopedic report directly, with Jordan's name and file number on each page as the form asks, and sends Forms 21-4142 and 21-4142a for the therapy clinic.

Section VI: 5103 notice acknowledgment (Item 23)

This section applies to compensation, pension, Dependency and Indemnity Compensation and accrued-benefit claims. If VA issued the decision you are reviewing within the past year, skip it. If the decision is more than a year old, read VA's page on the evidence needed for a disability claim, which is the notice required by 38 U.S.C. 5103, and check Yes to certify you reviewed it. If you check No, VA mails you the notice instead. Jordan's decision is under a year old, so Jordan skips Item 23.

Section VII: Notifying VA health care (Item 24)

Item 24 applies only to a compensation claim for a condition tied to military sexual trauma when you are enrolled in VA health care. It lets you consent, decline or revoke consent for the benefits office to alert VA health care about upcoming exams, Board hearings and decision notices. A response is not required. Jordan checks D, not applicable.

Sections VIII to XI: Signatures (Items 25 to 29)

Jordan signs Item 25A and dates 25B. Section IX (Items 26 and 27) is for two witnesses only if the claimant signs with an "X." Section X (Item 28) is for an alternate signer, who needs VA Form 21-0972 on file. Section XI (Items 29A to 29D) is for a representative's signature, which VA accepts only if a current VA Form 21-22 or 21-22a is on record.

Make the evidence answer the denial reason

A report that is newer but repeats what VA already knew may not change anything. Put the denial reason beside what the new record says:

Medical opinions show why this matters. In Claim Raven's analysis of 2024 to 2025 Board decisions, condition records where the Board described the medical opinion as strong were favorable 89.7% of the time, compared with 3.7% where it described the opinion as weak. The Board's quality rating partly reflects its own conclusion, and these are already-disputed appeals, so the figures describe what the Board rewards, not your odds; the full breakdown is on Claim Raven's VA disability statistics page. The new and relevant evidence examples show what qualifies.

Timing and where to send it

You can file a Supplemental Claim at any time, but VA's decision review FAQ recommends filing within one year of the decision letter to keep your effective date. For disability compensation you can file online. On paper, use the mailing address on page 1 of the form for your benefit type; for compensation it is Department of Veterans Affairs, Compensation Intake Center, P.O. Box 4444, Janesville, WI 53547. The form also accepts submission in person at a regional office or upload through QuickSubmit. Keep a copy of the form, the attachment list and the confirmation.

If you want a cover letter that explains the new evidence, Sample 1 in the appeal letter samples is written for a Supplemental Claim. If you are not sure the Supplemental Claim is the right review, the comparison of review options sets out the evidence rules for each.

To find the exact denial reason in a long letter, Claim Raven's Raven Eye gives each account one free starter analysis of a decision letter or Disability Benefits Questionnaire; Claim Raven sells the tool, and it does not file the Supplemental Claim.

Sources and scope

Checked September 23, 2026: VA Form 20-0995 (VA's form page lists the May 2024 revision; the PDF supersedes the September 2022 edition) and its printed instructions, VA's Supplemental Claim page and decision review FAQ. Board figures come from Claim Raven's analysis of 2024 to 2025 decisions and count condition records. Jordan Lee and every entry above are fictional.