VA Form 21-0519c-1 Improved Pension Eligibility Verification Report (Child

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

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(CHILD OR CHILDREN)
9C

VETERAN’S SOCIAL SECURITY NUMBER

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) prior to completing this form.

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 EACH
CHILD
(First, middle initial, last)

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

C. SOCIAL SECURITY
NUMBER

D. MARITAL STATUS

E. SCHOOL STATUS

F. ATTENDED SCHOOL
CONTINUOUSLY
SINCE AGE 18
DATE LEFT
SCHOOL

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED

(2)

STOPPED SCHOOL (1)

YES

(3)

NEVER MARRIED

(3)

DISABLED CHILD

NO

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED

(2)

STOPPED SCHOOL (1)

YES

(3)

NEVER MARRIED

(3)

DISABLED CHILD

NO

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED

(2)

STOPPED SCHOOL (1)

YES

(3)

NEVER MARRIED

(3)

DISABLED CHILD

NO

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED

(2)

STOPPED SCHOOL (1)

YES

(3)

NEVER MARRIED

(3)

DISABLED CHILD

NO

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED

(2)

STOPPED SCHOOL (1)

YES

(3)

NEVER MARRIED

(3)

DISABLED CHILD

NO

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED

(2)

STOPPED SCHOOL (1)

YES

(3)

NEVER MARRIED

(3)

DISABLED CHILD

NO

(2)

(2)

(2)

(2)

(2)

(2)

2. DID ANY CHILD ON THIS AWARD RECEIVE WAGES AT ANY TIME DURING THE LAST 12 MONTHS?

YES
VA FORM
JUN 2004

NO

21-0519C-1

SUPERSEDES VA FORM 21-0519C-1, SEP 2001, WHICH
WILL NOT BE USED.

(Continued on Reverse)

REPORT OF INCOME AND NET WORTH
IMPORTANT NOTE ABOUT ITEMS 3A THROUGH 3G:
Child Claimants or Payees: If you are a child claiming or receiving pension in your own right, report your income and net worth in
the CHILD columns. Leave the CUSTODIAN columns blank.
Custodians of Children: If you are claiming or receiving pension as the custodian of a child or children, report the child’s income and net worth in
the CHILD columns, and enter your income and net worth in the CUSTODIAN columns. If you are also the child’s parent, you are married, and you
live with your spouse, add your and your spouse’s incomes and net worth together and enter the totals in the CUSTODIAN columns in Items 3A, 3B,
and 3G.
Institutional Custodians: If you are an institutional custodian of a child, report the child’s income and net worth in the CHILD columns. Leave the
CUSTODIAN columns blank.

If no income was received from a particular source, write "0" or "none." Do not leave any items blank unless the instructions specifically
indicate that the item does not have to be answered.
3A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
GROSS MONTHLY AMOUNTS
CUSTODIAN:

CHILD:

CHILD:

SOURCE
SOCIAL SECURITY

$

$

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
OTHER RETIREMENT
OTHER (Show Source)
OTHER (Show Source)

3B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
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.
SOURCE

CUSTODIAN:
FROM:

FROM:

CHILD:
FROM:

FROM:

CHILD:
FROM:

FROM:

THRU:

THRU:

THRU:

THRU:

THRU:

THRU:

$

GROSS WAGES FROM ALL
EMPLOYMENT

$

$

$

$

$

TOTAL INTEREST AND DIVIDENDS
ALL OTHER (Show Source)

3C. 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 3D through 3F. If "NO," go to Item 3G.)
(1)
YES (2)
NO
3E. WHEN DID THE INCOME CHANGE?
3F. HOW DID INCOME CHANGE? (Tell
3D. WHAT INCOME CHANGED? (Show what
(Show the dates you received any new
what happened; for example, quit work,
income changed; for example, wages,
city pension, etc.)
income or the date income changed)
got raise, received inheritance)

3G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
SOURCE

CUSTODIAN:

CASH/NON-INTEREST-BEARING BANK ACCOUNTS
INTEREST-BEARING BANK ACCOUNTS

CHILD:

$

CHILD:

$

$

IRA’S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY
4. CHILD’S 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.
5. CHILD’S EDUCATIONAL EXPENSES (Read Paragraph 7 of the EVR Instructions)
If a school child answered "YES" to Items 1F and 2, report any educational expenses the child paid out of his/her own funds during the past 12 months.

A. SCHOOL CHILD’S NAME

B. AMOUNT PAID
$
$

6A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

6B. DATE SIGNED

6C. 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.