Form VA Form 21-4165 VA Form 21-4165 Pension Claim Questionnaire for Farm Income

OMB Approved No. 2900-0095
Respondent Burden: 30 minutes
1. VA FILE NUMBER

PENSION CLAIM QUESTIONNAIRE
FOR FARM INCOME

C/SS-

PRIVACY ACT NOTICE: The 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 5, Code of Federal Regulations 1.526 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 Compensation, Pension, Education, and Rehabilitation Records - VA, and published in the Federal
Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38
USC 5101 (c) (1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to
January 1, 1975, and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your
eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans
Affairs.
RESPONDENT BURDEN: We need this information to determine eligibility for disability pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1521, death pension under 38 U.S.C.
1541 and 1542, parents dependency and indemnity compensation under 38 U.S.C. 1121. We estimate that you will need an average 30 minutes to review the instructions, find the information
and complete this 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.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

INSTRUCTIONS: Before further action can be taken on your claim, we must have more information concerning your farming activity. Please answer all questions on
this form accurately and completely. If the answer to a particular question is none, write "NONE" in the space provided.
References in this form to "THIS YEAR" refer to the period
(If blank, "THIS YEAR" refers to the current calendar year. References
to "LAST YEAR" refer to the 12 month period preceding "THIS YEAR.")
2. FIRST - MIDDLE - LAST NAME OF VETERAN

PERIOD STARTING DATE

3. SOCIAL SECURITY NUMBER

PERIOD ENDING DATE

4. VA OFFICE AND ADDRESS

5. REPORT OF THE TOTAL OF ALL GROSS RECEIPTS
(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, etc.)
A. AMOUNT RECEIVED LAST YEAR

$

B. AMOUNT EXPECTED THIS YEAR

C. AMOUNT ANTICIPATED NEXT YEAR

$

$

6. NAMES OF OWNERS OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH (As shown by deed, trust or other document)

7. FARM OPERATING EXPENSES
(Include landlord’s share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)
ITEM
(A)
HIRED LABOR

AMOUNT
SPENT LAST
YEAR
(B)

AMOUNT TO
BE SPENT
THIS YEAR
(C)

ITEM
(D)

AMOUNT
SPENT LAST
YEAR
(E)

AMOUNT TO
BE SPENT
THIS YEAR
(F)

(Cols. B and E)

(Cols. C and F)

$

$

OTHER EXPENSES (List)

FEEDS PURCHASED
SUPPLIES PURCHASED
MACHINE HIRE
REPAIRS AND MAINTENANCE OF
FARM BUILDINGS AND MACHINERY
(Except dwellings)
CASH RENT
PROPERTY TAXES
INSURANCE ON PROPERTY
INTEREST ON MORTGAGE AND OTHER
LOANS (Not payment on principal)
VA FORM
APR 2004

21-4165

TOTAL EXPENSES
EXISTING STOCKS OF VA FORM 21-4165, JUL 2001,
WILL BE USED.

8A. TOTAL ACREAGE OWNED BY
YOU

8B. ACREAGE RENTED TO OTHERS

8C. ACREAGE RENTED FROM
OTHERS

9. ACREAGE IN CROPS AND PASTURE

10. LIVESTOCK INFORMATION

NUMBER OF ACRES

KIND
(Grain, hay, cotton, tobacco, etc.)

LAST YEAR

8D. TOTAL ACREAGE OPERATED BY YOU

KIND
(Cattle, pigs, sheep, ducks, etc.)

THIS YEAR

TOTAL NUMBER
ON FARM NOW

PASTURE

11. TOTAL FARM WORK
(Furnish the following information about the work done by you, hired help and others)
YEAR
(A)

LAST
YEAR

THIS
YEAR

PROPORTION (Check applicable boxes)
(C)

ITEM

LINE
NO.

(B)

NONE

1

PROPORTION DONE BY YOU

2

PROPORTION DONE BY HIRED HELP

3

PROPORTION DONE BY OTHERS
(Including members of the family)

4

PROPORTION BEING DONE BY YOU

5

PROPORTION BEING DONE BY HIRED HELP

6

PROPORTION BEING DONE BY OTHERS
(Including members of the family)

1/4

1/2

3/4

ALL

12. PLEASE DESCRIBE ANY WORK YOU HAVE DONE FOR OTHERS DURING THE PAST YEAR AND THE AMOUNT OF SALARY OR WAGES YOU RECEIVED

13. DO YOU RENT YOUR FARM TO OR FROM SOMEONE ELSE?

(If "Yes," furnish a copy of your farm rental agreement or lease or a statement setting forth in detail particulars of the agreement)
NO
YES
14. DO YOU RECEIVE INCOME FROM ANY SOURCE OTHER THAN FARMING?
YES

NO

(If "Yes," explain fully, including income received)

CERTIFICATION AND SIGNATURE OF CLAIMANT

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15A. DATE SIGNED

15B. SIGNATURE OF CLAIMANT

15C. DAYTIME PHONE NO. (Including Area
Code)

16. ADDRESS

15D. EVENING PHONE NO. (Including Area
Code)
WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK

Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and addresses
of such witnesses must be shown below.
17A. SIGNATURE OF WITNESS

17B. PRINTED NAME AND ADDRESS OF WITNESS

18A. SIGNATURE OF WITNESS

18B. PRINTED NAME AND ADDRESS OF WITNESS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a
material fact, knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.