Form 21-509 Statement of Dependency of Parent(s)

INSTRUCTIONS
FOR STATEMENT OF DEPENDENCY OF PARENT(S)
VA FORM 21-509
Note: Read very carefully, detach, and keep these instructions for your reference. Print all answers clearly. If an
answer is "none" or "0," write that. Your answer to every question is important to help us complete your claim. If
you do not know the answer, write "unknown." If additional space is necessary, please attach a separate sheet
indicating the item to which the answer applies.
A. How can I contact VA if I have questions?
If you have questions about this form, how to fill it out, or about benefits, contact your nearest VA regional
office. You can locate the address of the nearest regional office in your telephone book blue pages under "United
States Government, Veterans" or call 1-800-827-1000 (Hearing Impaired TDD line 1-800-829-4833). You may
also contact VA by Internet at http://www.vba.va.gov/benefits/address.htm.
B. What do I use VA Form 21-509 for?
Use VA Form 21-509 if:
1. You are a veteran whose parents are dependent on you for support, and you are:

.Receiving compensation benefits based on a 30 percent or higher service-connected disability, or
.Receiving VA educational benefits based on enrollment of 1/2 time or more.
OR
2. You are the parent of a deceased veteran who:

.Died on active duty or as a result of service-connected injuries or disease prior to January 1, 1957, or
.Died on or after May 1, 1957, and before January 1, 1972, while a waiver of premiums of his/her
U.S. Government Life Insurance was in effect.
C. What is meant by "Father" and "Mother" on this form?
The terms "Father" and "Mother" include a natural father or mother, a father or mother through adoption, and a
foster father or mother (including stepparents who stood in the relationship of parent to the veteran).

Specific Instructions
Net Worth of Parent(s) (Items 5A, 5B, and 5C)
Report the current value of all the interest and rights you have in any kind of property. This includes real estate,
stocks, bonds and the amount of bank deposits, savings and loan accounts, and cash on hand. However, net worth
does not include your single family dwelling unit and a reasonable lot area and personal things you use everyday
like your vehicle, clothing, and furniture. If property is owned jointly by yourself and your spouse, report one-half
of the total value held jointly for each of you.
Income of Parent(s) (Items 6A, 6B, and 6C)
Report all income received for the 12 month period and for the calendar month immediately preceding the date of
completing this form, and the sources of income.

VA FORM
DEC 2010

21-509

The term "income" means payments and benefits received from sources such as:

.Wages or salary (before any deductions) earned by all members of the parent(s) household, including
.minors
contributions to the family by adult members outside of the household
.Actual
Social Security benefits, retirement pay, allotments, and family allowances
.Pension, compensation or insurance benefits (other than those received from the Department of Veterans
.Affairs
and dividends
.Interest
Rents, property, business, and farm operations
When reporting net income for a business, farm, etc. attach a separate sheet showing gross income and itemized
expenses. Net income is gross income less the expenses of operating a rental property or a business or farm. Gross
income includes both receipts in cash and the market value of goods or services received in lieu of cash. Expenses
include cost of goods sold (for businesses), normal repairs, taxes, salary or wages of employees, insurance,
interest on business debts (but not payment of principal), supplies purchased, and other similar expenses.
Expenses of Parent(s) (Items 7A, 7B, 7C and 8)
Report the expenses for the 12 month period and for the calendar month immediately preceding the date of
completing this form. Include expenses for rent (or housing), home repairs, maintenance, clothing, medical care,
utilities, groceries, taxes, etc.
Dependents (Items 9A, 9B, 10A, 10B, 10C, and 10D)
Item 9A is to be completed by the parent(s) of a deceased veteran. Item 9B is to be completed by the veteran.
Items 10A, 10B, 10C, and 10D are to be completed whenever the parent(s) have dependents residing with the
parent(s).
Note: Parent(s) must sign and date the form (Items 11A, 11B, 12A, and 12B). A veteran claiming his/her
parent(s) as dependent(s) must also date and sign the form (Items 13A and 13B).
Privacy Act Notice: 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, and published in the Federal Register. Your obligation
to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory.
Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). 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 that you furnish may be utilized in computer matching programs with other
Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to
collect any amount owed to the United States by virtue of your participation in any benefit program administered
by the Department of Veterans Affairs.
Respondent Burden: We need this information to determine eligibility to benefits for dependanct parents. Title
38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30
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.

VA FORM 21-509, DEC 2010

OMB Approved No. 2900-0089
Respondent Burden: 30 minutes

STATEMENT OF DEPENDENCY OF PARENT(S)
Important - Please read the attached instructions before completing this form.
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

3A. FULL NAME OF VETERAN’S MOTHER

2. VA FILE NUMBER

3B. DATE OF BIRTH

4A. FULL NAME OF VETERAN’S FATHER

3C. SOCIAL SECURITY
NUMBER

4B. DATE OF BIRTH

4C. SOCIAL SECURITY
NUMBER

5. NET WORTH
B.
PRESENT
MARKET VALUE

A.

OWNER

DESCRIPTION OF PROPERTY (Include location of real property)

$

C.
ENCUMBRANCE
ON PROPERTY

$

VETERAN’S
MOTHER

VETERAN’S
FATHER

PRESENT
SPOUSE
OF MOTHER
OR FATHER

6. INCOME
B.
INCOME FOR LATEST
CALENDAR MONTH
FROM EACH SOURCE

A.

MEMBER
OF
FAMILY

SOURCE FROM WHICH INCOME IS RECEIVED

$
VETERAN’S
MOTHER

VETERAN’S
FATHER

PRESENT
SPOUSE
OF MOTHER
OR FATHER

VA FORM
DEC 2010

21-509

EXISTING STOCKS OF VA FORM 21-509, JUN 2004,
WILL BE USED.

C.
TOTAL FOR
12 MONTHS

$

EXPENSES OF PARENT(S) (Including spouse if remarried)
INSTRUCTIONS - Enter below the expenses for the 12 month period and for the calendar month immediately preceding the date of completing this form, and the
purposes for which paid out. Include expenses for rent (or housing), home repairs, maintenance, clothing, medical care, utilities, groceries, taxes, etc.

7B. EXPENSES FOR
LAST CALENDAR MONTH

7A. TYPE OF EXPENSE (List separately)

$

7C. TOTAL FOR
12 MONTHS

$

8. IF EXPENSES EXCEED INCOME, STATE FROM WHAT SOURCE SUCH EXPENSES ARE MET

9A. PARENTS ONLY - ARE THERE ANY PERSONS LIVING IN YOUR HOUSEHOLD DEPENDENT SOLELY UPON YOU FOR SUPPORT?

YES

NO

(If "YES," complete Items 10A, 10B, 10C and 10D)

9B. VETERANS ONLY - ARE THERE ANY PERSONS LIVING IN YOUR PARENT(S)’ HOUSEHOLD DEPENDENT SOLELY UPON YOU FOR SUPPORT?

YES

NO

(If "YES," complete Items 10A, 10B, 10C and 10D)
INFORMATION RELATING TO PERSONS SOLELY DEPENDENT UPON PARENT(S) (If additional space is needed use separate sheet)

10B. DATE
OF BIRTH

10A. NAME OF DEPENDENT PERSONS

10C. RELATIONSHIP TO
PARENT(S)

10D. REASON FOR DEPENDENCY

I CERTIFY THAT the following statements are true and correct to the best of my knowledge and belief.
11A. DATE

11B. SIGNATURE OF MOTHER

11D. DAYTIME PHONE NUMBER

11E. EVENING PHONE NUMBER

(

)

(

)

12A. DATE

12B. SIGNATURE OF FATHER

12D. DAYTIME PHONE NUMBER

12E. EVENING PHONE NUMBER

(

)

(

12C. ADDRESS OF FATHER

)

13A. DATE

13B. SIGNATURE OF VETERAN

13D. DAYTIME PHONE NUMBER

13E. EVENING PHONE NUMBER

(

(

)

11C. ADDRESS OF MOTHER

13C. ADDRESS OF VETERAN

)

WITNESSES - If you sign by (X), your mark must be witnessed by two persons who know you personally and the signature and address of such witnesses
must be shown.
14A. SIGNATURE OF WITNESS

14B. ADDRESS OF WITNESS

15A. SIGNATURE OF WITNESS

15B. ADDRESS OF WITNESS

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, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-509, DEC 2010