Form VA Form 21-0571 VA Form 21-0571 Application for Exclusion of Children's Income

OMB Control No. 2900-0510
Respondent Burden: 45 minutes

APPLICATION FOR EXCLUSION OF CHILDREN’S INCOME
PRIVACY ACT INFORMATION: 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, 58VA21/22, Compensation,
Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us
your and your dependents’ SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are
claimed 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. 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.
RESPONDENT BURDEN: We need this information to determine whether we can exclude all or part of your children’s income on the basis of hardship (38 U.S.C.
1521 and 38 U.S.C. 1541). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 45 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.
IMPORTANT: VA can exclude all or some of your children’s income in computing your rate of pension if counting the children’s income would cause hardship or if
this income is unavailable to you. Please fully complete this form if you wish to claim the exclusion.
1. FIRST, MIDDLE, LAST NAME OF VETERAN
2. VA FILE NUMBER
3. NAME OF CLAIMANT (If other than veteran)

4. VETERAN’S SOCIAL SECURITY NUMBER

5. ADDRESS OF CLAIMANT (No. and street or rural route, City or P. O., State, and ZIP Code)

CHILD’S NAME

CHILD’S NAME

CHILD’S NAME

CHILD’S NAME

ITEMS

6. CHILD’S DATE OF BIRTH

7. CHILD’S SOCIAL SECURITY NUMBER
8. IS ALL OF THIS CHILD’S INCOME
REASONABLY AVAILABLE TO YOU?
(If "No," complete Items 9 thru 13. If "Yes,"
skip to Item 14)

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

9. DESCRIBE THE SPECIFIC INCOME
WHICH IS NOT AVAILABLE TO YOU
(For example, Social Security, wages, etc.)
10. NAME OF PAYEE OF THE INCOME
DESCRIBED IN ITEM 9? (Whose name
appears on the check?)
11. DOES THE PERSON NAMED IN ITEM
10 RESIDE IN YOUR HOUSEHOLD
ALL YEAR? (If "No," complete Item 12.
If "Yes," skip to Item 13)
12. HOW MANY MONTHS DID THE
PERSON NAMED IN ITEM 10 RESIDE
IN YOUR HOUSEHOLD DURING THE
12 MONTHS PRECEDING THE DATE
YOU ARE SIGNING THIS FORM?
13. USE THIS SPACE TO FURNISH ANY
OTHER INFORMATION AS TO WHY
YOU FEEL THIS CHILD’S INCOME IS
NOT REASONABLY AVAILABLE TO
YOU (If you need more space, use
Item 17)
VA FORM
AUG 2004

21-0571

EXISTING STOCKS OF VA FORM 21-0571, OCT 2001,
WILL BE USED.

(Continued on Reverse)

14. AVERAGE MONTHLY EXPENSES FOR YOUR HOUSEHOLD
IMPORTANT: Use the space below to report your average monthly household expenditures. The figures you report should reflect
your expenses for the 12 months preceding the date you sign this form. Do not report medical expenses on this form. Report medical
expenses on your Eligibility Verification Report (EVR). VA will mail you an Eligibility Verification Report annually. If more space
is needed to show expenses, use Item 17, Remarks.
ITEM
ITEM
AVERAGE MONTHLY EXPENSE
AMOUNT
AVERAGE MONTHLY EXPENSE
AMOUNT
NO.
NO.
RENT OR MORTGAGE
FURNITURE AND HOUSEHOLD
A
J
PAYMENTS
GOODS
B

FOOD

C

UTILITIES AND HEAT

D

TELEPHONE

L

E

OPERATION OF
AUTOMOBILE

M

F

PUBLIC TRANSPORTATION

N

G

CLOTHING

O

H

TAXES

P

INSURANCE (Specify type. If
more than one, furnish amount
paid for each)

Q

I

15. DO YOU EXPECT THAT THE LEVEL OF HOUSEHOLD EXPENSES
SHOWN IN ITEM 14 WILL CHANGE SIGNIFICANTLY DURING THE
NEXT 12 MONTHS?
YES
NO (If "Yes," explain fully in Item 17)
17. REMARKS (If you need more space, attach a continuation sheet)

K

INTEREST PAYMENTS
OTHER LIVING EXPENSES
(Specify)

R
16. HAS THERE BEEN ANY CHANGE IN THE INCOME OF ANY MEMBER
OF YOUR HOUSEHOLD SINCE THE LAST TIME YOU REPORTED
YOUR INCOME TO VA? (Do not report Social Security or VA cost-of-living
adjustments)
YES

NO (If "Yes," explain fully in Item 17)

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
18A. SIGNATURE OF CLAIMANT

18B. DATE

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