VA Form 21-0514-1 DIC Parent's Eligibility Verification Report

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

DIC PARENT’S ELIGIBILITY
VERIFICATION REPORT

VETERAN’S SOCIAL SECURITY NUMBER

4

VA FILE NUMBER - PAYEE NUMBER - STUB NAME
FIRST, MIDDLE, LAST NAME OF PARENT
VA REGIONAL OFFICE RETURN ADDRESS
COMPLETE ADDRESS OF PARENT

IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER

1B. YOUR SPOUSE’S SOCIAL SECURITY NUMBER

1C. YOUR DATE OF BIRTH (Mo., day, year)

1D. YOUR SPOUSE’S DATE OF BIRTH (Mo., day, year)

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 within the last
12 months, show the date of separation

(4)

NOT NOW MARRIED (You have never married or are now divorced or widowed.) If your most recent marriage
ended during the last 12 months, enter the date of divorce or the date of your spouse’s death.)
Date of divorce
Date of spouse’s death

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. WERE YOU OR YOUR SPOUSE EMPLOYED AT ANY TIME DURING THE 12
MONTH PERIOD PRECEDING THE DATE YOU SIGNED THE FORM?

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

YES
VA FORM
JUN 2004

NO

21-0514-1

(If "YES," write in the VA file number of the other benefit)
SUPERSEDES VA FORM 21-0514-1, AUG 1999,
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

YOUR SPOUSE

$

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
MILITARY RETIREMENT

OTHER (Show Source)

OTHER (Show Source)
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

SOURCE
GROSS WAGES FROM
ALL EMPLOYMENT

YOUR SPOUSE

FROM:

FROM:

FROM:

FROM:

THRU:

THRU:

THRU:

THRU:

$

$

TOTAL INTEREST AND
DIVIDENDS
ALL OTHER
(Show Source)
ALL OTHER
(Show Source)
7C. 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.)
(If "YES," complete Items 7D through 7F. If "NO," go to Item 8.)
YES
NO
7D. WHAT INCOME CHANGED? (Show what
7E. WHEN DID THE INCOME CHANGE? (Show
income changed; for example, wages,
the dates you received any new income or
city pension, etc.)
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)

Normally, medical expenses are reported at the end of the year. If you are using this form as your annual Eligibility
Verification Report and 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. If you are using this form as a supplement to
a pending claim, you do not need to report medical expenses. If entitlement is established, you will have an opportunity
to report your medical expenses at the end of the year.
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.