VA Form 21-0518-1 Improved Pension Eligibility Verification Report (Surviv

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

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
FIRST NAME - MIDDLE NAME - LAST NAME OF SURVIVING SPOUSE

(SURVIVING SPOUSE WITH NO CHILDREN)
VA FILE NUMBER

COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE

VA REGIONAL OFFICE RETURN ADDRESS

8

IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER

1B. VETERAN’S SOCIAL SECURITY NUMBER

1C. YOUR DATE OF BIRTH (Mo., day, yr.)

2. YOUR MARITAL STATUS (Check only one box)
(1)

I HAVE NOT REMARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran’s death.)

(2)

I REMARRIED ON
(Date) AND I AM STILL MARRIED (You married after the veteran’s death and you are currently
married. Enter the date you married your current spouse.)

(3)

I REMARRIED AFTER THE VETERAN DIED BUTTHE MARRIAGE ENDED BY DEATH OR DIVORCE ON
(You remarried but you are not currently married. Show the date your latest marriage ended.)

.

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

NOT IN YOUR CUSTODY

AMOUNT CONTRIBUTED DURING PAST 12 MONTHS TO CHILDREN NOT IN YOUR CUSTODY $
4C. ENTER THE NAME, COMPLETE ADDRESS, AND
TELEPHONE NUMBER OF NURSING HOME
(Please include ZIP Code)

4A. ARE YOU A PATIENT IN A NURSING HOME?

YES
NO (If "YES," complete Items 4B through 4D. If "NO," go to Item 5.)
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?
NO
YES
5. DID YOU RECEIVE ANY WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS?

NO
YES
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE ?

YES
VA FORM
JUN 2004

NO (If "YES," write in the VA file number of the other benefit)

21-0518-1

SUPERSEDES VA FORM 21-0518-1, OCT 2001,
WHICH WILL NOT BE USED.

(Continued on Reverse)

7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
If no income or net worth was received from a particular source, write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
SOURCE

SURVIVING SPOUSE

SOCIAL SECURITY
U.S. CIVIL SERVICE

$

U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
OTHER (Show Source)
OTHER (Show Source)
7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
If no income was received from a particular source, write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
NOTE: Report annual income for the dates indicated. If no dates are shown above the columns that follow, then report last calendar
year (January through December) income in the left-hand column and current calendar year income in the right-hand column.
FROM:
FROM:
SOURCE
THRU:
THRU:
GROSS WAGES FROM
ALL EMPLOYMENT
$
TOTAL INTEREST AND
DIVIDENDS

$

ALL OTHER
(Show Source)
ALL OTHER
(Show Source)
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING PAST 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 or if you received any NEW
source of income or any ONE-TIME income)
YES
NO (If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)
7D. WHAT INCOME CHANGED? (Show what
7E. WHEN DID THE INCOME CHANGE?
income changed; for example, wages,
(Show the dates you received any new
city pension, etc.)
income or the date income changed)

7F. HOW DID INCOME CHANGE?
(Explain what happened; for example,
quit work, got raise, received inheritance)

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
SOURCE

SURVIVING SPOUSE

CASH/NON-INTEREST BEARING BANK ACCOUNTS

$

INTEREST BEARING BANK ACCOUNTS
IRA’S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY
8. FAMILY MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)

Normally, medical expenses are reported at the end of the year. If you are using this form as your annual Eligibility Verification Report
and 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. If you are using this form as a supplement to a pending claim, you do not need to report
medical expenses. If entitlement is established, you will have an opportunity to report your medical expenses at the end of the year.
9. SURVIVING SPOUSE’S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read
Paragraph 7 of the EVR Instructions). Show amounts paid by you during the past 12 months.
DO NOT REPORT CHILDRENS’ EXPENSES.
10A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

$
10B. DATE SIGNED

10C. TELEPHONE NUMBERS (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.