Form VA Form 21-8049 VA Form 21-8049 Request for Details of Expenses

OMB Approved No. 2900-0138
Respondent Burden: 15 Minutes

REQUEST FOR DETAILS OF EXPENSES
INSTRUCTIONS - We need additional information to determine whether you are entitled to benefits. Please complete all items. If an answer is
"none" or "0," write that. For additional space, use Item 12, "Remarks," or attach a separate sheet indicating the item number to which the answers
apply. If you have any questions or need assistance, please call 1-800-827-1000 (Hearing Impaired TDD line 1-800-829-4833).
1. NAME AND ADDRESS OF CLAIMANT

2. NAME OF VETERAN (First-middle-last)

3. VA FILE NUMBER

SECTION I - DEPENDENTS NOT LIVING WITH YOU
(List ONLY persons you support who DO NOT live with you)
4A. NAME

4B. AGE

4C. RELATIONSHIP

4D. AMOUNT YOU CONTRIBUTE TO SUPPORT
$

$

$

$

$

SECTION II - DEPENDENTS LIVING WITH YOU
(List ONLY persons you support who DO live with you)
5A. NAME

5B. AGE

5C. RELATIONSHIP

SECTION III - MONTHLY EXPENSES (EXCEPT MEDICAL) FOR YOU AND THOSE LISTED ABOVE AS LIVING WITH YOU
6A. ITEM

6B. AMOUNT

6A. ITEM (Cont’d)

6B. AMOUNT (Cont’d)

HOUSING

$

UTILITIES

$

FOOD

$

EDUCATION OF CHILDREN

$

TAXES

$

OTHER
(Specify)

$

INTEREST

$

CLOTHING
VA FORM
OCT 2010

$

$

21-8049

$
EXISTING STOCK OF VA FORM 21-8049, MAR 2003,
WILL BE USED.

SECTION IV - HOSPITAL AND MEDICAL EXPENSES
7A. DO YOU HAVE OR EXPECT TO HAVE ANY LARGE OR UNUSUAL HOSPITAL OR MEDICAL EXPENSES FOR
YOURSELF AND OTHERS YOU SUPPORT AND LIVE WITH?
YES
NO
7C. EXPLANATION

7B. ESTIMATED COST PER YEAR
$

SECTION V - EDUCATIONAL EXPENSES
8. DO YOU EXPECT TO MAKE PROVISIONS FOR YOUR CHILDREN’S EDUCATIONAL NEEDS, INCLUDING ADVANCED TECHNICAL OR COLLEGE EDUCATION?
YES

NO

SECTION VI - EXPENSES OF LAST ILLNESS AND BURIAL OF VETERAN, SPOUSE, OR CHILD
AND JUST DEBTS OF DECEASED VETERAN OR PARENT’S SPOUSE
9A. NAME OF DECEASED PERSON (First-middle-last)

9B. RELATIONSHIP TO YOU
WIFE

HUSBAND

9C. DATE OF DEATH
CHILD

EXPENDITURES FOR ABOVE-NAMED PERSON
NOTE - Furnish information concerning unreimbursed expenses as follows:
A VETERAN - For his/her spouse’s or child’s last illness and burial.
A SPOUSE - For the last illness and burial of veteran’s child.
A CHILD - For veteran’s last illness, burial and just debts.
A WIDOW(ER) - For veteran’s last illness, (paid before or after
A PARENT - For his/her spouse’s or veteran’s last illness and burial
the veteran’s death), burial and just debts and for the last
and for his/her spouse’s just debts.
illness and burial of veteran’s child.
10C. TOTAL
10A. NAME AND ADDRESS OF
10B. NATURE OF
10D. AMOUNT
10E. DATE
AMOUNT OF
PERSON TO WHOM PAID
EXPENSES OR DEBT
PAID
EXPENSES OR DEBT PAID BY YOU

$

$

$

$

$

$

$

$

SECTION VII - COMMERCIAL LIFE INSURANCE PAYMENTS
PAYMENTS
11A.

TOTAL RECEIVED OR EXPECTED BY CLAIMANT

11B.

EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments,
explain payment schedule in Item 12, Remarks)

AMOUNT
$

12. REMARKS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission or any statement or evidence of
a material fact, knowing it to be false.
I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
13. SIGNATURE OF CLAIMANT (Do not print, sign in ink)

14. DATE

15. TELEPHONE NUMBER(S) (Include Area Code)
A. DAYTIME

B. EVENING

PRIVACY ACT INFORMATION: 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, 58VA21/22/28, Compensation, Pension, Education and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information
is considered relevant and necessary to determine entitlement to benefits. 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 to determine entitlement to pension or parent’s dependency and indemnity compensation (38 U.S.C. 1503 and 1315).
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.reginfo.gov/public/do/PRAMain. If desired, you
can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.