Form FL21-914 Residency Verification Report (RVR) - Veterans and Survi

Department of
Veterans Affairs

In Reply Refer To:

What Is The Purpose Of This Letter?

We are sending you this letter to determine whether we can continue to pay your VA

compensation or dependency and indemnity compensation (Die) benefits at the full-dollar rate.

To receive benefits at the full-dollar rate you must:

be present in the U.S. for at least 183 days of each year, and
not be absent from the U.S. for more than 60 days at a time, and
be a U.S. citizen or permanent resident alien, and
let us know if you change your address.
What Must I Do Now?

Answer questions 1 throl,1gh 6 below to verify that you continue to be eligible for VA benefits at

the full-dollar rate.

What Will Happen If I Don't Complete and Return This Letter?

If we do not receive a response from you within 60 days from the date of this letter, your benefits

will be reduced to the half-dollar rate.

Do You Have Questions or Need Assistance?
If you have any questions or need assistance, please call 1-800-827-1000 (Hearing Impaired
TDD line 1-800-829-4833).

Department of Veterans Affairs
OMB Approved No. 2900-0655
Respondent Burden' 20 minutes
1. DID YOU LEAVE THE UNITED STATES (states, territories, and possessions, the District of Columbia and Puerto Rico) at
any time during calendar year
? Note: Do not include any trip, such as a trip to Mexico or Canada, in which you left
from and returned to the U.S. on the same day.
(If "Yes," attach a separate sheet of paper listing each period of absence separately, showing
the date you left the United States and the date you returned, and send us a copy of your passport visas or
reentry permits with entrance and exit date stamps.)
DYES
NO
2. DID YOU LOSE YOUR U.S. CITIZENSHIP OR PERMANENT RESIDENT ALIEN STATUS DURING CALENDAR YEAR
7

o

(If "Yes," send us a copy of the Immigration and Naturalization Service (INS) notice which shows the

date that your citizenship or permanent resident alien status ended.)

DYES

3A. DID YOU NOTIFY US OF A CHANGE IN YOUR ADDRESS DURING CALENDAR YEAR
?

nNO

n NO purchase
(If "No," complete Item 38, and send us evidence that you live at this address, such as a current lease or

a(lreement or utility bill (telephone, (las or electric.)

n
YES
38. CURRENT STREET MAILING ADDRESS (Number, street, or rural route, city, state, and ZIP Code)
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge.
4. SIGNATURE
5. DATE SIGNED
6. TELEPHONE NO.(S) (Include Area Code)
Daytime
Evening

I

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 knowina it to be false.
FL21·914
See Reverse For Important Information
JUN 2004

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 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 122, Compensation, Pension,
Educations and Rehabilitation Records - VA, published in the Federal Register. Your obligation to
respond is required to obtain or retain benefits. The requested information is considered relevant
and necessary to determine maximum benefits under the law. The responses you submit are
considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through
computer matching programs with other agencies.
IMPORTANT NOTICE ABOUT INFORMATION COLLECTION: We need this information to verify
that you are eligible for payment of benefits at the full-dollar rate (38 U.S.C. 107). Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of
20 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.

FL 21-914

JUN 2004