VA Form 21-0516-1 Improved Pension Eligibility Verification Report

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

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(VETERAN WITH NO CHILDREN) 6
VA FILE NUMBER
YOUR COMPLETE MAILING ADDRESS
VA REGIONAL OFFICE RETURN ADDRESS

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. FIRST, MIDDLE, LAST NAME OF SPOUSE

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

2. MARITAL STATUS (Check only one box)
(1)

MARRIED LIVING WITH SPOUSE (You are legally married and you live with your spouse or are separated
for medical reasons.)

(2)

MARRIED NOT LIVING WITH SPOUSE (You are legally married but estranged from your spouse.) Show the amount you
contributed to your spouse’s support during the last 12 months $

.

If you separated within the last 12 months, show the date of separation
(3)

.

NOT MARRIED (You have never married or are now divorced or widowed.) If your marriage ended within the last 12 months,
show the date of divorce or death

.

3. NUMBER OF UNMARRIED, DEPENDENT CHILDREN (See Paragraph 1 of the EVR Instructions, VA Form 21-0510)
IN YOUR CUSTODY

NOT IN YOUR CUSTODY

AMOUNT CONTRIBUTED DURING PAST 12 MONTHS TO CHILDREN NOT IN YOUR CUSTODY $
4C. ENTER THE NAME, COMPLETE ADDRESS, AND
TELEPHONE NUMBER OF NURSING HOME
(Please include ZIP Code)

4A. ARE YOU A PATIENT IN A NURSING HOME?
YES
NO (If "YES," complete Items 4B through 4D. If "NO," go to Item 5.)
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?
YES
NO
4E. SHOW THE DATE YOUR MEDICAID COVERAGE STARTED

5. DID EITHER YOU OR YOUR SPOUSE RECEIVE ANY WAGES OR WERE EITHER OF YOU EMPLOYED AT ANY TIME DURING THE PAST 12
MONTHS?
NO
YES
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE ?

YES
VA FORM
JUN 2004

NO (If "YES," write in the VA file number of the other benefit)

21-0516-1

SUPERSEDES VA FORM 21-0516-1, OCT 2001,
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

VETERAN

SPOUSE

SOCIAL SECURITY
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.

NOTE: Report annual income for the dates indicated. If no dates are shown above the columns that follow, then report last calendar
year (January through December) income in the left-hand column and current calendar year income in the right-hand column.
VETERAN

SOURCE

GROSS WAGES FROM
ALL EMPLOYMENT

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 7G.)
YES
NO
7E. WHEN DID THE INCOME CHANGE?
7D. WHAT INCOME CHANGED? (Show what
(Show the dates you received any
income changed; for example, wages,
new income or the date income changed)
city pension, etc.)

7F. HOW DID INCOME CHANGE?
(Explain what happened; for example,
quit work, got raise, received inheritance)

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
VETERAN

SOURCE

CASH/NON-INTEREST-BEARING BANK ACCOUNTS

$

SPOUSE
$

INTEREST-BEARING BANK ACCOUNTS
IRA’S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY
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.
9. VETERAN’S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR Instructions)

Show amounts paid by you during the last 12 months. DO NOT REPORT DEPENDENTS’ EXPENSES.
10A. SIGNATURE OF VETERAN (Read Paragraph 9 of the EVR Instructions before signing)

10B. DATE SIGNED

10C. 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.

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