VA Form 21-0519c Improved Pension Eligibility Report (Child or Children)

OMB Approved No. 2900-0101
Respondent Burden : 30 minutes
VA REGIONAL OFFICE

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(CHILD OR CHILDREN)
9C
VA FILE NUMBER - PAYEE NUMBER - STUB NAME
PAYEE ADDRESS
VA REGIONAL OFFICE RETURN ADDRESS

IF YOU DO NOT RETURN THE COMPLETED FORM TO VA BY

YOUR BENEFITS WILL BE DISCONTINUED.

IMPORTANT -Please read the enclosed EVR Instructions (VA Form 21-0510) prior to completing this form.

1. CHILD(REN)’S MARITAL AND SCHOOL STATUS

List the children’s names, dates of birth, and Social Security numbers, and indicate marital and school status for all
children being paid on this award. If the child does not have a Social Security number, write "No SSN" in the space
provided for the child’s Social Security number. If other children are on separate VA awards, they will receive their own
EVRs. If additional space is needed, attach a separate sheet of paper.

NOTE: Complete Item 1E only if the child is 18 years of age or older. Complete Item 1F only if the child is between the ages of 18 and 23 and has
not been rated disabled by VA. The child is considered to have attended school continuously if the child attended every regular school term except summer school or holiday periods. If Block
(2), STOPPED SCHOOL, is checked in Item 1E or "NO" is checked in Item 1F, provide the date the child last attended school in Item 1F.

A. FULL NAME OF EACH
CHILD
(First, middle initial, last)

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

C. SOCIAL SECURITY
NUMBER

D. MARITAL STATUS

MARRIED

(2)

DIVORCED/WIDOWED

(3)

NEVER MARRIED

(1)

MARRIED

NEVER MARRIED

(1)

MARRIED

NEVER MARRIED

(1)

(3)

DISABLED CHILD

(1)

ATTENDS SCHOOL

(2)

STOPPED
SCHOOL

(3)

DISABLED CHILD

(1)

ATTENDS SCHOOL

(2)

STOPPED
SCHOOL

MARRIED

(1)

ATTENDS SCHOOL

DIVORCED/WIDOWED

(2)

(1)

STOPPED
SCHOOL

(3)

DISABLED CHILD

MARRIED

(1)

ATTENDS SCHOOL

DIVORCED/WIDOWED

(2)

(3)

NEVER MARRIED

(1)

MARRIED

(3)

STOPPED
SCHOOL

DISABLED CHILD

NEVER MARRIED

(2)

(2)

DIVORCED/WIDOWED
NEVER MARRIED

STOPPED
SCHOOL

(3)

DISABLED CHILD

(1)

ATTENDS SCHOOL

(2)
(3)

F. ATTENDED SCHOOL
CONTINUOUSLY
SINCE AGE 18
DATE LEFT
SCHOOL

ATTENDS SCHOOL

(3)

(3)

(2)

YES

DIVORCED/WIDOWED

(3)

(2)

VA FORM
JUN 2004

DIVORCED/WIDOWED

(3)

(2)

5. DID ANY CHILD ON THIS AWARD RECEIVE WAGES AT ANY TIME DURING

(1)

(1)

(2)

E. SCHOOL STATUS

STOPPED
SCHOOL

(1)

YES

(2)

NO

(1)

YES

(2)

NO

(1)

YES

(2)

NO

(1)

YES

(2)

NO

(1)

YES

(2)

NO

(1)

YES

(2)

NO

DISABLED CHILD

?

NO

21-0519C

SUPERSEDES VA FORM 21-0519C, OCT 1996, WHICH
WILL NOT BE USED.

(Continued on Reverse)

REPORT OF INCOME AND NET WORTH
IMPORTANT NOTE ABOUT ITEMS 3A THROUGH 3G:
Child Claimants or Payees: If you are a child claiming or receiving pension in your own right, report your income and net worth in
the CHILD columns. Leave the CUSTODIAN columns blank.
Custodians of Children: If you are claiming or receiving pension as the custodian of a child or children, report the child’s income and net worth in
the CHILD columns, and enter your income and net worth in the CUSTODIAN columns. If you are also the child’s parent, you are married, and you
live with your spouse, add your and your spouse’s incomes and net worth together and enter the totals in the CUSTODIAN columns in Items 3A, 3B,
and 3G.
Institutional Custodians: If you are an institutional custodian of a child, report the child’s income and net worth in the CHILD columns. Leave the
CUSTODIAN columns blank.

If no income was received from a particular source, write "0" or "none." Do not leave any items blank unless the instructions
specifically indicate that the item does not have to be answered.
3A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
SOURCE

CUSTODIAN:

SOCIAL SECURITY (See Note Below)

CHILD:

$

CHILD:

$

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
OTHER RETIREMENT
OTHER (Show Source)
OTHER (Show Source)

NOTE: If an amount is preprinted in one or more of the Social Security blocks above and the amount is correct, you are not required to make any entry in
that Social Security block. (Read Paragraph 3 of the EVR Instructions)
3B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
CUSTODIAN:

CHILD:

CHILD:

SOURCE
GROSS SALARY OR WAGES

$

$

$

$

$

$

TOTAL INTEREST AND DIVIDENDS
ALL OTHER (Show Source)

3C. DID ANY INCOME CHANGE (Increase/Decrease) DURING
? (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 3D through 3F. If "NO," go to Item 3G.)
3D. WHAT INCOME CHANGED? (Show what
3E. WHEN DID THE INCOME CHANGE?
income changed, for example, wages,
(Showthe dates you received any new
city pension, etc.)
income or the date income changed)

3F. HOW DID INCOME CHANGE? (Tell
what happened; for example, quit work,
got raise, received inheritance)

3G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
SOURCE

CUSTODIAN:

CASH/NON-INTEREST-BEARING BANK
INTEREST-BEARING BANK ACCOUNTS

CHILD:

$

CHILD:

$

$

IRA’S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY
4. CHILD’S MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)
A. Our records show that during
the child(ren) paid medical expenses of $
ON THIS LINE. GO DIRECTLY TO 4D IF $0 APPEARS IN 4A, OTHERWISE GO TO 4B.)

. (MAKE NO ENTRY

B. Enter the amount of unreimbursed medical expenses the child(ren) paid during

.$

C. Enter the amount of unreimbursed medical expenses the child(ren) will pay during
.$
D. If an amount greater than $0 is printed in 4A and you entered amounts in 4B and 4C which are substantially the same as the
amount printed in 4A, you do not have to complete the VA Form 21-8416 that was sent to you with this EVR. However, you
may be required to complete VA Form 21-8416 and furnish proof of payments at a later date. If $0 is printed in Item 4A or if
an amount is printed in 4A but it is not substantially the same as the amounts you entered in 4B and 4C, you must submit
VA Form 21-8416 with this EVR in order to claim a medical expense deduction or continue an existing deduction.
5. CHILD’S EDUCATIONAL EXPENSES (Read Paragraph 7 of the EVR Instructions)
If a school child answered "YES" to Items 1F and 2, report any educational expenses the child paid out of his/her own funds during

A. SCHOOL CHILD’S NAME

.

B. AMOUNT PAID
$
$

6A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

6B. DATE SIGNED

6C. 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.