VA Form 21-0519s-1 Improved Pension Eligibility Verification Report (Surviv

OMB Approved No. 2900-0101
Respondent Burden : 40 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(SURVIVING SPOUSE WITH CHILDREN) 9S

FIRST , MIDDLE, LAST NAME OF SURVIVING SPOUSE

VA FILE NUMBER

COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE

VA REGIONAL OFFICE RETURN ADDRESS

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 (Month, Day, Year)

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

I HAVE NOT MARRIED 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 BUT THE MARRIAGE ENDED BY DEATH OR DIVORCE ON
(You remarried but you are not currently married. Show the date your latest marriage ended.)

(DATE)

3A. UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions)
FULL NAME OF EACH
CHILD
(First, middle initial, last)

DATE OF
BIRTH
(Mo., day, yr.)

PLEASE CHECK ONE (X)
SOCIAL SECURITY
NUMBER

UNDER 18
YEARS OF AGE

OVER 18 AND UNDER ANY AGE PERMANENTLY
23, AND ATTENDING HELPLESS FOR MENTAL
SCHOOL
OR PHYSICAL REASONS

3B. UNMARRIED DEPENDENT CHILDREN LISTED IN 3A WHO DO NOT LIVE WITH YOU
NAME OF CHILD

CHILD’S COMPLETE ADDRESS

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

NAME OF PERSON CHILD LIVES
WITH (If Applicable)

MONTHLY AMOUNT YOU
CONTRIBUTE TO CHILD’S

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

NO (If "YES," complete Items 4B through 4D. If "NO," go to Item 5.)
YES
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?

YES

NO

YES

NO

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

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)

21-0519S-1

SUPERSEDES VA FORM 21-0519S-1, JAN 1997,
WHICH WILL NOT BE USED.

(Continued on Reverse)

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

SOURCE

SURVIVING SPOUSE

SOCIAL SECURITY

$

CHILD:

CHILD:

$

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
OTHER 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:

SOURCE

SURVIVING SPOUSE
FROM:

THRU:
GROSS SALARY OR WAGES
FROM ALL EMPLOYMENT

THRU:

$

$

CHILD:
FROM:

FROM:

CHILD:
FROM:

FROM:

THRU:

THRU:

THRU:

THRU:

$

$

$

$

TOTAL INTEREST
AND DIVIDENDS
ALL OTHER (Show Source)

ALL OTHER (Show Source)

7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE 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.)
(If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)
YES
NO
7E. WHEN DID THE INCOME CHANGE?
7D. WHAT INCOME CHANGED? (Show what
(Showthe dates you received any
income changed, for example, wages,
new income or the date income changed)
city pension, etc.)

7F. HOW DID INCOME CHANGE? (Tell
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

$

CHILD:

CHILD:

$

$

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. 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 last 12 months. DO NOT REPORT CHILDRENS’ EXPENSES.

$

10. FAMILY MAINTENANCE (HARDSHIP) EXPENSES FOR NEXT 12 MONTHS (Read Paragraph 8 of the EVR Instructions)
Complete ONLY IF VA is currently excluding children’s income on the grounds of hardship. Show total family expenses expected for the next
12 months. $
11A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

11B. DATE

11C. 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.