OMB Control No.

2900-0862
Respondent Burden: 15 minutes
Expiration Date: 4/30/2024
VA DATE STAMP
DO NOT WRITE IN THIS SPACE

DECISION REVIEW REQUEST: HIGHER-LEVEL REVIEW

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 5.
Use this form to request a Higher-Level Review of a decision you received. A Higher-Level Review is a new
review of an issue(s) previously decided by VA based on the evidence of record at the time of the prior
decision. For more information call us toll-free at 1-800-827-1000. If you use a Telecommunications Device
for the Deaf (TDD), the Federal relay number is 711. VA forms are available at www.va.gov/vaforms.
SECTION I - VETERAN'S IDENTIFICATION INFORMATION
NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter
per box, and completely fill in each applicable circle to help expedite processing of the form.
1. VETERAN'S NAME (First, Middle Initial, Last)

R O M E O D O N A T O
2. SOCIAL SECURITY NUMBER 3. VA FILE NUMBER (If applicable) 4. DATE OF BIRTH (MM/DD/YYYY)

5 5 7 6 0 5 3 8 8 0 3 1 8 1 9 3 9
5. VA INSURANCE POLICY NUMBER (If applicable)

6. CURRENT MAILING ADDRESS (Number, street or rural route, City or P.O. Box, State and ZIP Code and Country)
No. &
Street
2 9 6 5 D E S E R T B R O O K L A N E
Apt./Unit Number City B U L L H E A D
State/Province A Z Country U S ZIP Code/Postal Code 8 6 4 2 9
● I AM HOMELESS OR AT RISK OF HOMELESSNESS

7. TELEPHONE NUMBER (Include Area Code)

9 2 8 2 3 4 5 0 9 5 Enter International Phone Number (If applicable)

8. E-MAIL ADDRESS (Optional)

r o n d o n a t o 1 8 @ g m a i l . c o m
SECTION II - CLAIMANT'S IDENTIFICATION INFORMATION (If other than veteran)
9. CLAIMANT'S NAME (First, Middle Initial, Last)

10. SOCIAL SECURITY NUMBER (If applicable) 11. DATE OF BIRTH (MM/DD/YYYY) (If applicable)

12. CURRENT MAILING ADDRESS (Number, street or rural route, City or P.O. Box, State and ZIP Code and Country)
No. &
Street

Apt./Unit Number City

State/Province Country ZIP Code/Postal Code

13. TELEPHONE NUMBER (Include Area Code)

Enter International Phone Number (If applicable)

14. E-MAIL ADDRESS (Optional)

SECTION III - BENEFIT TYPE

15. SELECT ONLY ONE (If you file for multiple benefit types, you must complete a separate VA Form 20-0996 for each benefit type.)
COMPENSATION ● PENSION/SURVIVORS BENEFITS ● FIDUCIARY ● EDUCATION ● VETERANS HEALTH ADMINISTRATION
● VETERAN READINESS AND EMPLOYMENT ● LOAN GUARANTY ● LIFE INSURANCE ● NATIONAL CEMETERY ADMINISTRATION

VA FORM
APR 2021 20-0996 SUPERSEDES VA FORM 20-0996, FEB 2019 Page 3
 SECTION IV - OPTIONAL INFORMAL CONFERENCE
16. YOU OR YOUR AUTHORIZED REPRESENTATIVE MAY REQUEST AN INFORMAL CONFERENCE WITH THE HIGHER-LEVEL REVIEWER FOR THE SOLE
PURPOSE OF POINTING OUT ERRORS OF FACT OR LAW IN THE PRIOR DECISION. (VA will only conduct one informal conference by telephonic communication
associated with this request for Higher-Level Review.)

16A. I WOULD LIKE AN INFORMAL CONFERENCE. I understand electing an informal conference is optional and may delay a decision.

16B. IF YOU SELECTED THE BOX ABOVE, VA will make two attempts to contact you OR your representative to schedule the informal conference. Contact attempts
will be between the hours of 8:00 a.m. and 4:30 p.m. Eastern Time. INDICATE ONE PREFERENCE:

Call me between 8:00 a.m. - 12:00 p.m. ET Call me between 12:00 p.m. - 4:30 p.m. ET

● Call my representative between 8:00 a.m. - 12:00 p.m. ET ● Call my representative between 12:00 p.m. - 4:30 p.m. ET
17. IF YOU WOULD LIKE VA TO CONTACT YOUR REPRESENTATIVE, YOU MUST PROVIDE YOUR REPRESENTATIVE'S CONTACT INFORMATION BELOW.
17A. REPRESENTATIVE'S NAME (First, Last)

17B. REPRESENTATIVE'S TELEPHONE NUMBER (Include Area Code)

17C. REPRESENTATIVE'S E-MAIL ADDRESS

SECTION V - SOC/SSOC OPT-IN FROM LEGACY APPEALS SYSTEM

18. By marking the circle below, I ELECT TO PARTICIPATE IN THE MODERNIZED REVIEW SYSTEM for the following issues decided in a Statement of the Case (SOC) or
Supplemental Statement of the Case (SSOC). I am withdrawing the eligible appeal issues listed in 19A in their entirety, and any associated hearing requests, from the
legacy appeals system. I understand I cannot return to the legacy appeals system for the issue(s) withdrawn. TO OPT-IN, THE CIRCLE BELOW MUST BE MARKED.
OPT-IN FROM SOC/SSOC

NOTE: Add the date of the SOC or SSOC in block 19B for all appeal issues being withdrawn.

SECTION VI - ISSUES FOR HIGHER-LEVEL REVIEW

19. INDICATE EACH ISSUE DECIDED BY VA FOR WHICH YOU ARE REQUESTING A HIGHER-LEVEL REVIEW. Refer to your decision notice(s) for a list of adjudicated
issues. For each issue, identify the date of VA's most recent decision on the issue. You may attach additional sheets, if necessary - include your name and file number on
each additional sheet. IMPORTANT: You may only list issues for the benefit type selected in Section III. A separate form is required for each benefit type.
19A. SPECIFIC ISSUE(S) OF DISAGREEMENT (REQUIRED) 19B. DATE OF VA DECISION NOTIFICATION
LETTER (REQUIRED)

Example 1: Service connection for left knee MM/DD/YYYY

Example 2: Earlier effective date for hearing loss MM/DD/YYYY
Example 3: Reimbursement for non-VA emergency care MM/DD/YYYY
Example 4: Denial of entitlement to VR&E benefits and services MM/DD/YYYY
Example 5: Entitlement to Service-Disabled Veterans Insurance MM/DD/YYYY

My VA disability rating for insomnia disorder with secondary

alcohol use disorder uncomplicated, which I also claimed as
generalized anxiety disorder, is currently denied. 0 4 2 6 2 0 2 3
However, my submitted evidence, including an Independent
Psychological Opinion,updated medical records, and
statements, were not considered in the review.

I respectfully request that the VA re-evaluate my case and

take into consideration the evidence provided, which supports
a 30% disability rating.

VA FORM 20-0996, APR 2021 Page 4

 SECTION VI - ISSUES FOR HIGHER-LEVEL REVIEW (Continued)
19A. SPECIFIC ISSUE(S) OF DISAGREEMENT (REQUIRED) 19B. DATE OF VA DECISION NOTIFICATION
LETTER (REQUIRED)

SECTION VII - CERTIFICATION AND SIGNATURE

NOTE: This section is MANDATORY and completion is required to process your claim unless accompanied by VA Form 21-0972, Alternate Signer
Certification or Section VIII is completed.
I CERTIFY the statements on this form are true and correct to the best of my knowledge and belief.

20A. SIGNATURE OF VETERAN OR CLAIMANT (Sign in ink) 20B. DATE SIGNED

SECTION VIII - AUTHORIZED REPRESENTATIVE SIGNATURE

I CERTIFY the statements on this form are true and correct to the best of my knowledge and belief.

NOTE: A representative's signature will not be accepted unless at the time of submission of this request a valid VA Form 21-22, Appointment of Veterans
Service Organization as Claimant's Representative, or VA Form 21-22a, Appointment of Individual as Claimant's Representative, indicating the
appropriate representative is of record with VA or included with this application.
21A. NAME OF VA AUTHORIZED REPRESENTATIVE (First, Last)

21B. SIGNATURE OF VA AUTHORIZED REPRESENTATIVE (Sign in ink) 21C. DATE SIGNED

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.
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, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is voluntary.

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 15 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.
VA FORM 20-0996, APR 2021 Page 5