VA Form 21-0514 DIC Parent's Eligibility Verification Report

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

DIC PARENT’S ELIGIBILITY
VERIFICATION REPORT

4

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.
1A. YOUR SOCIAL SECURITY NUMBER (Enter correct number if
wrong or missing)

1C. ARE THE SOCIAL SECURITY NUMBERS SHOWN ABOVE
CORRECT?

YES

NO

1B. YOUR SPOUSE’S SOCIAL SECURITY NUMBER (Enter correct number if
wrong or missing)

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

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

(If "NO,"enter correct Social Security Numbers
in Items 1A and/or 1B)

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

MARRIED LIVING WITH OTHER PARENT OF VETERAN (You are currently married and live with the veteran’s other
parent or you live apart only for medical reasons.)

(2)

MARRIED LIVING WITH SPOUSE WHO IS NOT OTHER PARENT OF VETERAN (You are currently married to
a person who is not the veteran’s other parent and you live together or live apart only for medical reasons.)

(3)

SEPARATED FROM SPOUSE (You are married but estranged from your spouse.) If you separated in
separation.

(4)

NOT NOW MARRIED (You have never married or are now divorced or widowed.) If your most recent marriage ended in
, enter the date of divorce or the date of your spouse’s death.)
Date of divorce
Date of spouse’s death

,

show the date of

3. IS THE OTHER PARENT OF THE VETERAN LIVING?

YES
NO
UNKNOWN
4A. ARE YOU A PATIENT IN A NURSING HOME?

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

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

5. DID YOU OR YOUR SPOUSE RECEIVE ANY WAGES AT ANY TIME DURING

?

NO
YES
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE ?
YES
VA FORM
JUN 2004

NO

21-0514

(If "YES," write in the VA file number of the other benefit)
SUPERSEDES VA FORM 21-0514, JUL 1995, 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

YOU

SOCIAL SECURITY
(See NOTE below)

YOUR SPOUSE

$

$

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

NOTE: If an amount is preprinted in one or both 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.
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.
YOU

YOUR SPOUSE

SOURCE
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
? (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 NEWsource of income or any ONE-TIME income.)

YES

NO

(If "YES,"complete Items 7D through 7F. If "NO," go to Item 8.)

7D. WHAT INCOME CHANGED? (Show what
income changed, for example, wages,
city pension, etc.)

7E. WHEN DID THE INCOME CHANGE?
(Show the dates you received any new
income or the date income changed)

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

8. MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)
A. Our records show that during
expenses in the amount of $
IF $0 APPEARS IN 8A, OTHERWISE GO TO 8B.)

you and your spouse paid unreimbursed medical
(MAKE NO ENTRY ON THIS LINE. GO DIRECTLY TO 8D

B. ENTER THE AMOUNT OF UNREIMBURSED MEDICAL EXPENSES YOU PAID DURING

$

C. ENTER THE AMOUNT OF UNREIMBURSED MEDICAL EXPENSES YOU WILL PAY DURING

$

D. If an amount greater than $0 is printed in 8A and you entered amounts in 8B and 8C which are substantially the same as the amount printed in 8A,
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 8A or if an amount is printed in 8A but it is not substantially the same as the
amounts you entered in 8B and 8C, you must submit VA Form 21-8416 with this EVR in order to claim a medical expense deduction or continue an
existing deduction.
9A. SIGNATURE OF PARENT (Read Paragraph 9 of the EVR Instructions before signing)

9B. DATE SIGNED

9C. 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.