VA Form 21-0512v-1 Old Law and Section 306 Eligibility Verification Report

OMB Approved No. 2900-0101
Respondent Burden: 30 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN

OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
2V
(VETERAN)
YOUR COMPLETE MAILING ADDRESS

VA FILE NUMBER
VA REGIONAL OFFICE RETURN ADDRESS

IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21-0510) before completing this form. This form
is used by veterans receiving Old Law or Section 306 Pension. If you have been receiving a fixed rate of pension
since 1960, you receive Old Law Pension. If you have been receiving a fixed rate of pension since 1978, you
receive Section 306 Pension. If you receive Old Law Pension, do not complete Item 7G, Net Worth, and Item 8,
Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1A. YOUR SOCIAL SECURITY NUMBER

1B. YOUR SPOUSES’S SOCIAL SECURITY NUMBER

1C. FIRST NAME - MIDDLE NAME - LAST NAME OF YOUR SPOUSE

1D. YOUR SPOUSE’S DATE OF BIRTH (Mo., day, yr.)

2. MARITAL STATUS (Check one box)

(1)

MARRIED-LIVING WITH SPOUSE (You are legally married and live with your spouse or you live apart
only for medical reasons.)

(2)

MARRIED-NOT LIVING WITH SPOUSE (You are legally married but estranged from your spouse.)
Show the amount you contributed to your spouse’s support during the last 12 months
If you separated within the last 12 months, show the date of separation

(3)

NOT MARRIED (You have never married or are now divorced or widowed.)
If your marriage ended within the last 12 months, show the date of divorce or death

3A. NUMBER OF UNMARRIED DEPENDENT CHILDREN (See Paragraph 1 of the EVR Instructions)
IN YOUR CUSTODY

3B. AMOUNT CONTRIBUTED DURING PAST 12
MONTHS TO CHILDREN NOT IN YOUR CUSTODY

$

NOT IN YOUR CUSTODY

4A. ARE YOU A PATIENT IN A NURSING HOME? (If "YES," Complete Items 4B thru 4D. If "NO," go to Item 5.)
YES

NO

4B. SHOW THE DATE YOU ENTERED THE NURSING HOME

4C. ENTER THE NAME, COMPLETE ADDRESS, AND TELEPHONE
NUMBER OF THE NURSING HOME ( Please include ZIP Code)

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?
YES

NO

5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS?
YES

NO

6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
YES
VA FORM
JUN 2004

NO

(If you checked "YES," write in the VA File number of the other benefit)

21-0512V-1

SUPERSEDES VA FORMS 21-0511V-1, NOV 1996 AND
21-0512V-1, MAY 2003, WHICH WILL NOT BE USED.

(Continued on Reverse)

7. REPORT OF INCOME AND NET WORTH
NOTE - If no income or net worth was received from a particular source, write "0"or "none." DO NOT LEAVE ANY ITEMS BLANK.
Exception: Report your spouse’s income only if you receive Section 306 Pension.
A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
GROSS MONTHLY AMOUNTS

SOURCE

VETERAN
$

SOCIAL SECURITY
U.S. CIVIL SERVICE

SPOUSE - SECTION 306 ONLY
$

U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY INCOME
(SSI)/PUBLIC ASSISTANCE
OTHER MONTHLY INCOME
(Show Source)
7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
NOTE - If no income was received from a particular source, write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
Exception: Report your spouse’s income only if you receive Section 306 Pension.
LAST YEAR

SOURCE
VETERAN
GROSS WAGES FROM ALL
EMPLOYMENT

$

THIS YEAR

SPOUSE -Sec. 306 Only
$

VETERAN
$

SPOUSE -Sec. 306 Only
$

TOTAL INTEREST AND DIVIDENDS
ALL OTHER (Show Source)
ALL OTHER (Show Source)
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE LAST 12 MONTHS? (Answer "NO" if there were no income changes or if the
only change was a Social Security/VA cost-of-living adjustment. Answer "YES" if there were any other income changes of if you received any
NEW source of income or any ONE-TIME income)
(1)
YES (2)
NO (If "YES," complete Items 7D, through 7F. If "NO," go to Item 7G.)
7D. WHAT INCOME CHANGED?
7E. WHEN DID THE INCOME CHANGE?
7F. HOW DID INCOME CHANGE?
(Show what income changed; for example, wages, (Show the dates you received any new income or (Explain what happened; for example, quit work, got
city pension, etc.)
the date income changed)
raise, received inheritance)

7G. VETERAN’S NET WORTH (Read Paragraph 5 of the EVR Instructions)
NOTE: Complete only if you receive Section 306 Pension. Skip to Item 9A if you receive Old Law Pension.
SOURCE
CASH/NON-INTEREST BEARING BANK
ACCOUNTS

VETERAN
$

SURVIVING SPOUSE
$

INTEREST BEARING BANK ACCOUNTS
IRAs, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY
(Not your home)
ALL OTHER PROPERTY
8. FAMILY MEDICAL EXPENSES

NOTE: Skip to Item 9A if you receive Old Law Pension.

If Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21-8416,
Medical Expense Report, to report your medical expenses.
9A. SIGNATURE OF CLAIMANT, CUSTODIAN OR GUARDIAN (Read Paragraph 9 of the EVR Instructions before signing)

9B. DATE

10. TELEPHONE NUMBER (Include Area Code)
DAYTIME

EVENING

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 is false, or fraudulent acceptance of any payment to which you are not entitled.