VA Form 21-0513-1 Old Law and Section 306 Eligibility Verification Report

OMB Control No. 2900-0101
Respondent Burden: 30 minutes
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

OLD LAW AND SECTION 306
VERIFICATION REPORT
(CHILDREN ONLY)

VETERAN’S SOCIAL SECURITY NUMBER

NAME OF CHILD’S CUSTODIAN

3

VA FILE NUMBER
COMPLETE MAILING ADDRESS OF CHILD OR CUSTODIAN
VA REGIONAL OFFICE RETURN ADDRESS

IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21-0510) before completing this form. This form is used by children and custodians
of children receiving Old Law or Section 306 Pension. If you have been receiving a fixed rate of pension since 1960, you receive Old Law Pension. If
you have been receiving a fixed rate of pension since 1978, you receive Section 306 pension. If you receive Old Law Pension, do not complete Item 2G,
Net Worth, and Item 3, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
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
CHILD
(First, middle initial, last)

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

C. SOCIAL
SECURITY
NUMBER

E. SCHOOL STATUS

D. MARITAL STATUS
(1)
(2)
(1)
(2)

MARRIED
(1)
DIVORCED/WIDOWED (2)
NEVER MARRIED
(3)
(1)
MARRIED
DIVORCED/WIDOWED (2)

(3)
(1)

NEVER MARRIED
MARRIED

(3)

(2)
(3)
(1)
(2)
(3)
(1)
(2)
(3)

(3)

ATTENDS SCHOOL
STOPPED SCHOOL
DISABLED CHILD
ATTENDS SCHOOL
STOPPED SCHOOL
DISABLED CHILD

(1)
DIVORCED/WIDOWED (2)
NEVER MARRIED
(3)

ATTENDS SCHOOL
STOPPED SCHOOL

MARRIED
(1)
DIVORCED/WIDOWED (2)
NEVER MARRIED
(3)
(1)
MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED (2)
(3)
NEVER MARRIED

DISABLED CHILD
STOPPED SCHOOL
DISABLED CHILD
ATTENDS SCHOOL
STOPPED SCHOOL
DISABLED CHILD

F. ATTENDED SCHOOL
CONTINUOUSLY SINCE
AGE 18

(1)

YES

(2)

NO

(1)

YES

(2)

NO

(1)

YES

(2)

NO

(1)

YES

(2)

NO

(1)

YES

(2)

NO

DATE LEFT
SCHOOL

2. REPORT OF INCOME AND NET WORTH
NOTE: If no income was received from a particular source, write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)

SOURCE
SOCIAL SECURITY

CHILD’S NAME:

$

CHILD’S NAME:

$

CHILD’S NAME:

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY
INCOME (SSI)
OTHER INCOME (Show source)

OTHER INCOME (Show source)

VA FORM
JUN 2004

21-0513-1

SUPERSEDES VA FORM 21-0513-1, JUN 2001
WHICH WILL NOT BE USED.

(Continued on Reverse)

2B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
If no income was received write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
CHILD
SOURCE

GROSS SALARY OR WAGES

FROM:
THRU:

$

CHILD
FROM:
THRU:

$

CHILD

FROM:
THRU:

FROM:
THRU:

$

FROM:
THRU:

$

FROM:
THRU:

$

$

TOTAL INTEREST AND
DIVIDENDS
ALL OTHER (Show Source)
ALL OTHER (Show Source)
2C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE PAST 12 MONTHS? (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 2D through 2F. If "NO," go to Item 2G.)

2D. WHAT INCOME CHANGED?
(Show what income changed; for
example, wages, city pension, etc.)

2E. WHEN DID THE INCOME CHANGE?
(Show the dates you received any new
income or the date income changed)

2F. HOW DID INCOME CHANGE?
(Explain what happened: for example, quit
work, got raise, received inheritance)

2G. NET WORTH (Read Paragraph 5 of the EVR Instructions)

NOTE: Complete only if you receive Section 306 Pension. Skip to Item 4A if you receive Old Law Pension.
SOURCE

CHILD

CHILD

CHILD

CASH/NON-INTEREST BEARING BANK
ACCOUNTS

INTEREST-BEARING BANK ACCOUNTS

STOCKS, BONDS, MUTUAL FUNDS, ETC.

CERTIFICATES OF DEPOSIT, IRAs, ETC.

REAL PROPERTY (Excluding child’s home)

ALL OTHER PROPERTY
3. CHILD’S MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)
NOTE: Skip to Item 4A if you receive Old Law Pension.

If Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21-8416,
Medical Expense Report, to report your medical expenses.
4A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

4B. DATE

5. TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME

B. 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.