Form 21-8941 REPS Annual Eligibility Report (Under the Provisions of

OMB Approved No. 2900-0405
Respondent Burden: 15 minutes

REPS ANNUAL ELIGIBILITY REPORT
(Under the Provisions of Section 156, Public Law 97-377)
PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22, Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation
to respond is required to obtain or retain benefits. Giving us your SSN account information is voluntary. Providing your SSN will help ensure that your records are properly associated with
your claim file. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the
disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine
maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching
programs with other agencies.
RESPONDENT BURDEN: We need this information in order to determine continued eligibility for REPS benefits (38 U.S.C. 5101 (a)). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can
be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or
suggestions about this form.
1C. VETERAN’S/WAGE EARNER’S
SOCIAL SECURITY NUMBER

1A. NAME OF CLAIMANT (First, middle, last)

1B. CLAIMANT’S SOCIAL SECURITY
NUMBER

2A. GROSS EARNINGS LAST YEAR

2B. ANTICIPATED GROSS EARNINGS THIS YEAR

$

$

3A. WERE YOU SELF-EMPLOYED
YES

3B. NUMBER OF HOURS WORKED
PER WEEK

NO

4A. ARE YOU CURRENTLY SELFEMPLOYED?
YES

4B. NUMBER OF HOURS WORKED
PER WEEK

NO

(If "Yes," complete Item 4B)

(If "Yes," complete Item 3B)

5. EMPLOYMENT HISTORY
A. DID YOU BEGIN WORKING
LAST YEAR?
YES

B. DATE YOU BEGAN WORKING

YES

NO

(If "Yes," complete Item 5B)

D. DATE YOU QUIT WORKING

NO

(If "Yes," complete Item 5D)

E. ARE YOU CURRENTLY EMPLOYED?
YES

C. DID YOU QUIT WORKING
LAST YEAR?

F. NAME AND ADDRESS OF YOUR EMPLOYER(S)

G. DO YOU ANTICIPATE
BEGINNING EMPLOYMENT THIS
YEAR?

NO

YES

NO

6. MARITAL STATUS
A. DID YOU REMARRY LAST YEAR OR
THIS YEAR TO DATE?
YES

B. DATE OF MARRIAGE

C. COMPLETE MARRIED NAME

NO

7. STATUS OF YOUNGEST DEPENDENT CHILD IN YOUR CARE WHILE AGE 16 TO 18
A. NAME OF CHILD OF THE VETERAN IN YOUR CARE BETWEEN THE AGES OF 16 AND 18 YEARS OLD

B. HAS THIS DEPENDENT MARRIED OR
OTHERWISE LEFT YOUR CARE?
YES

NO

(If "Yes," complete Items 7C - 7E)

C. DATE OF MARRIAGE

D. DATE CHILD LEFT YOUR CARE

E. EXPLAIN WHY CHILD IS NO LONGER IN YOUR CARE (If necessary use
Item 8)

8. REMARKS

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 to be false.
I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
9A. SIGNATURE OF CLAIMANT OR GUARDIAN

9B. DATE
DAYTIME

VA FORM
OCT 2004

21-8941

9C. TELEPHONE NO(S) (Including Area Code)
EVENING

EXISTING STOCKS OF VA FORM 21-8941, JAN 2002,
WILL BE USED.

INSTRUCTIONS
You will receive all benefits due you for the year if your total annual earning do not exceed the limit shown in
the letter attached to this form. If you earn more than the annual limit, then $1 will be deducted from your
benefits for each $2 you earn over that limit.
Item 2A - Gross Earnings Last Year
Enter your total gross wages for January through December of last year in the block provided. You must enter
all wages earned for the entire year, even if you received REPS benefits for only part of the year.
Your total gross wages for last year are generally the same as the highest dollar amount shown on your form(s)
W-2 for that year. Total gross wages include cash pay, cash tips of $20 or more a month for one employer,
certain wages-in-kind (unless you are a domestic or farm worker), bonuses, commissions, fees, vacation pay in
lieu of action, severance pay, and most sick pay. You must include this income, even if it is not shown on your
form(s) W-2. (Examples of income you do not have to report are listed below.)
Add the total net earnings (or loss) from self-employment as shown (or will be shown) on your Federal income
tax return (Schedule SE, Form 1040). If you report your income on a fiscal year basis, explain in Item 8. Be
sure to show beginning and ending dates of fiscal year.
Item 2B - Anticipated Gross Earnings This Year
If you expect to have earnings this year from wages, self-employment, or both, enter the highest amount you
estimate you will earn in the box provided. If you do not expect to have any earnings, write "NONE" in the
box. DO NOT leave the box blank. If you cannot furnish an estimate, enter "UNKNOWN."
IF YOU DO NOT COMPLETE ITEM 2B, NO BENEFIT CAN BE PAID FOR THE CURRENT YEAR
UNTIL YOU FILE A REPORT OF EARNINGS.
If you sold or transferred your business last year (or plan to do so in the current year), explain in Item 8. You
may be asked for information or documents concerning the transaction.
INCOME YOU DO NOT HAVE TO REPORT
Generally, you do not have to report income that is not earned from employment or self-employment such as:
Social security, railroad retirement, civil service, veterans’, black lung, or public assistance benefits
Pension and other retirement payments
Investment income, unless you are a dealer in securities
Interest from savings accounts
Life insurance annuities and dividends
Gain (or loss) from the sale of capital assets
Gifts or inheritances
Rental income, unless it is from a trade or business, or by a farm landlord materially participating in the
operation of the farm
Unemployment compensation
Jury duty payment
Sick pay received more than 6 months after you stopped working
Room and board furnished by your employer on his/her premises for his/her convenience (Living on
your employer’s premises must also be required by him/her for the value of the room not to count as
income.)
FOREIGN EARNINGS
Report in Item 8 the number of hours per month worked for each month employed if you had foreign earnings
that were not subject to U. S. Social Security (FICA) taxes.
VA FORM 21-8941, OCT 2004