Fillable Printable Form 8
Fillable Printable Form 8
Form 8
CERTIFICATION OF APPEAL
THE APPEAL IS FOR (State the question(s) at issue clearly and concisely.)
It is hereby certified that all material evidence is of record, that all contentions advanced by and on behalf of the appellant have been considered under all pertinent laws,
and the issues determined.
1A. NAME OF APPELLANT (If other than veteran)
1B. RELATIONSHIP TO VETERAN 2. FILE NO.
4. INSURANCE FILE NO. OR LOAN
NO. (If pertinent)
3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN
5A. SERVICE CONNECTION FOR
6A. INCREASED RATING FOR
7A. OTHER
5B. DATE OF NOTIFICATION OF
ACTION APPEALED
6B. DATE OF NOTIFICATION OF
ACTION APPEALED
7B. DATE OF NOTIFICATION OF
ACTION APPEALED
8A. APPELLANT REPRESENTED IN THIS APPEAL BY (Name of organization, attorney or agent)
8B. ONE OF THE FOLLOWING IS ON FILE AS AUTHORITY FOR RECOGNIZING SUCH REPRESENTATIVE IN THIS APPEAL
POWER OF ATTORNEY (WHEN SERVICE ORGANIZATION OR AGENT IS
REPRESENTATIVE, OR WHEN AN INDIVIDUAL IS RECOGNIZED PURSUANT
TO 38 U.S.C. 5903)
DECLARATION OF REPRESENTATIVE (WHEN ATTORNEY IS REPRESENTATIVE)
CERTIFICATION THAT VALID POWER OF ATTORNEY OR DECLARATION OF
REPRESENTATION IS IN ANOTHER VA FILE (If so, specify file)
8D. IF AGENT DESIGNATED, IS HE/SHE ON
ACCREDITED LIST?
YES
NO
8C. CHECK IF APPLICABLE
THERE IS ON FILE AN UNREVOKED POWER OF ATTORNEY AND A DECLARATION OF REPRESENTATION BY AN ATTORNEY.
CONSEQUENTLY, THE FILE CONTAINS A STATEMENT SIGNED BY THE APPELLANT WHICH CAN BE CONSTRUED AS AUTHORIZING
THE REPRESENTATIVE NAMED IN 8A ABOVE TO REPRESENT APPELLANT IN THIS APPEAL.
9A. IF REPRESENTATIVE IS SERVICE ORGANIZATION, IS VA FORM 646, OR EQUIVALENT,
OF RECORD?
YES NO
NO (If "YES." complete item 11B).
9B. IF VA FORM 646 IS NOT OF RECORD, EXPLAIN
YES
YES NO
YES
NO
YES NO
10B. IF HELD, IS TRANSCRIPT IN FILE?
11B. HAVE THE REQUIREMENTS OF 38 U.S.C. 7105A BEEN FOLLOWED?
12B. SUPPLEMENTAL STATEMENT OF THE CASE
REQUIRED AND FURNISHED NOT REQUIRED
10A. WAS HEARING REQUESTED?
10C. IF REQUESTED BUT NOT HELD, EXPLAIN
11A. ARE CONTESTED CLAIMS PROCEDURES APPLICABLE IN THIS CASE?
12A. DATE STATEMENT OF THE CASE FURNISHED
14. REMARKS (Continue on reverse)
CF OR XCF
INACTIVE CF
OTHER (Specify)
R&E F
TRAINING SUB-F
DEP. ED. F (Ch. 35)
LOAN GUAR. F
INSURANCE F
DENTAL F
OUTPATIENT F
HOSPITAL COR.
CLINICAL REC.
X-RAYS
SLIDES
TISSUE BLOCKS
15. NAME AND LOCATION OF CERTIFYING OFFICE
17A. SIGNATURE OF CERTIFYING OFFICIAL
18A. SIGNATURE OF MEDICAL MEMBER (Insurance use only)
16. ORGANIZATIONAL ELEMENT CERTIFYING APPEAL
17B. TITLE
18C. DATE
17C. DATE
18B. TITLE
JetFormVA FORM
OCT 1992(RS)
8
13. RECORDS TO BE FORWARDED TO BOARD OF VETERANS’ APPEALS
