DES Informal PEB Election of Options - secnav.navy.mil

1 DES Informal PEB Election of Options Initials:_____ Version: Updated: 16 May 18 Page 1 of 4 From: _____ Rank, First Name, MI, Last Name, Service, MTF To: President, Physical Evaluation Board (PEB) Subj: Disability Evaluation System Informal Physical Evaluation Board Election of Options Ref: (a) DODI (b) DODM Volumes 1 & 2 (c) SECNAVINST 1. I acknowledge receipt of my Physical Evaluation Board findings and appropriate counseling regarding my Election of Options . I understand my PEB findings and Options and choose the following option(s) in accordance with references (a) through (c). I understand the PEB will finalize my case (as Presumed Acceptance) if I do not choose an option within fifteen (15) calendar days from the day I received my findings.

2 2. I understand my right to consult with an attorney prior to completing this form. Upon my request, a government lawyer (at no charge) will be assigned to advise me. I also have the right to be represented by private counsel but at my expense. I understand my right to consult with an attorney does not delay my fifteen (15) calendar day period to decide my option(s). 3. I am aware of the Department of Veterans Affairs eBenefits web portal. I can access the eBenefits web portal at 4. I am aware of the Compensation and benefits handbook for Seriously Ill and Injured Members of the Armed Forces at 5. I understand that I may contest the combat relation component of my finding directly with OJAG, Code 13 instead of requesting a Formal PEB. 6. I understand Service Headquarters will determine my obligated service requirements (officers only).

3 7. I will initial the bottom of each page and the appropriate sections. DES Informal PEB Election of Options Initials:_____ Version: Updated: 16 May 18 Page 2 of 4 ACCEPT FINDINGS _____ I ACCEPT the Informal PEB s findings. I do not request a Formal PEB hearing and (initial as applicable): ____ (IDES ONLY) I request the VA reconsider my disability rating percentage(s) for my unfitting referred condition(s). For a VA rating reconsideration, I understand: The request for a VA rating reconsideration must include new medical evidence or sufficient justification of an error to warrant reconsideration. The Election of Options and VA rating reconsideration evidence must be submitted concurrently. The PEB will not accept multiple submissions of the Election of Options and VA rating reconsideration evidence.

4 The PEB will finalize my case (without forwarding for a VA rating reconsideration) if I fail to submit new medical evidence or sufficient justification of an error to warrant reconsideration within fifteen (15) calendar days from the day I received my findings. Upon receipt of the VA rating reconsideration results, the PEB will finalize my case, notify my service headquarters, and send me the VA rating reconsideration results. Although I am permitted only a one-time VA rating reconsideration while in the Disability Evaluation System, upon my separation/retirement I may appeal my disability ratings directly to the VA per 38 CFR Part 3. Additionally, I understand I have the opportunity to be represented before the VA by a VA-accredited attorney, agent, or representative of a VA-recognized Service organization.

5 Service members placed on the Temporary Disability Retired List must provide post-service contact information, if known. a. Mailing address: _____ b. E-mail address: _____ c. Cell phone: _____ DES Informal PEB Election of Options Initials:_____ Version: Updated: 16 May 18 Page 3 of 4 CONTEST FINDINGS _____I DO NOT ACCEPT the Informal PEB s findings and request a Formal PEB hearing to contest my fitness determination. I understand: The PEB will ONLY consider the fitness determination (Fit or Unfit) and will not consider the disability rating percentage(s); Rating percentage(s) are determined by the VA. The Formal PEB is a de novo proceeding. Upon commencement of a Formal PEB hearing previous findings may NOT be accepted, and the Formal PEB outcome can change.

6 A Formal PEB will be a full and fair hearing, and I will be appointed a government lawyer (at no charge) to represent me. I also have the right to be represented by private counsel at my own expense. The PEB will pay for my travel to Washington, DC for the formal hearing. I must read and sign the accompanying Privacy Act Disclosure Authorization. SERVICE MEMBER (OR AUTHORIZED REPRESENTATIVE) SIGNATURE Service Member Printed Name Service Member Signature Date **If signing for the Service member, a Power of Attorney must be provided with this Election of Options . PEBLO CERTIFICATION I certify upon the penalty of perjury that I fulfilled the counseling requirements in accordance with references (a) through (c), and that I forwarded the member s Election of Options to the Physical Evaluation Board.

7 PEBLO Printed Name PEBLO Signature Date DES Informal PEB Election of Options Initials:_____ Version: Updated: 16 May 18 Page 4 of 4 Privacy Act Disclosure Authorization Legal Authority: The Privacy Act of 1974 (5 552a); DoDM Release Statement: Submission of this document to your Physical Evaluation Board Liaison Officer constitutes your written authorization for the Physical Evaluation Board to disclose information and records about you, including information and records subject to the Privacy Act, to the office of the Judge Advocate General s Disability Evaluation System Program (OJAG Code 16) for use by your assigned government counsel in preparation of your case. Service Member Printed Name Service Member Signature Date Printed Name of Witness Witness Signature Date