VA Form 21-0517-1 Improved Pension Eligibility Verification Report -Vetera

OMB Approved No. 2900-0101
Respondent Burden : 40 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(VETERAN WITH CHILDREN) 7

YOUR COMPLETE MAILING ADDRESS

VA FILE NUMBER
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 separated from your spouse.) Show the
amount you contributed to your spouse’s support during the past 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

3A. UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions, VA Form 21-0510)
FULL NAME OF EACH
CHILD
(First, middle initial, last)

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

PLEASE CHECK ONE (X)
SOCIAL SECURITY
NUMBER

UNDER 18
YEARS OF AGE

OVER 18 AND UNDER
23, AND ATTENDING
SCHOOL

ANY AGE PERMANENTLY
HELPLESS FOR MENTAL
OR PHYSICAL REASONS

3B. UNMARRIED DEPENDENT CHILDREN LISTED IN ITEM 3A WHO DO NOT LIVE WITH YOU
NAME OF
CHILD

CHILD’S COMPLETE ADDRESS

NAME OF PERSON CHILD
LIVES WITH (If Applicable)

MONTHLY AMOUNT YOU
CONTRIBUTE TO CHILD’S
SUPPORT

$
$
$
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

4C. ENTER THE NAME, COMPLETE ADDRESS,
AND TELEPHONE NUMBER OF NURSING HOME
(Please include ZIP Code)

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?
YES
NO
5. DID EITHER YOU OR YOUR SPOUSE RECEIVE WAGES OR WERE EITHER OF YOU EMPLOYED AT ANY TIME
DURING THE PAST 12 MONTHS?
YES
NO
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)

21-0517-1

SUPERSEDES VA FORM 21-0517-1, NOV 2002,
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

CHILD:

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

7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
NOTE: Report annual income for the dates indicated. If no dates are above the columns that follow, then report last calendar year
(January thru December) income in the left-hand column and current calendar year income in the right-hand column.
If no income was received from a particular source, write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
VETERAN
SPOUSE
CHILD:
SOURCE
GROSS WAGES FROM
ALL EMPLOYMENT

FROM:

FROM:

FROM:

FROM:

FROM:

FROM:

THRU:

THRU:

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)
YES
NO (If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)
7F. HOW DID INCOME CHANGE? (Explain
7D. WHAT INCOME CHANGED? (Show what
7E. WHEN DID THE INCOME CHANGE?
what happened; for example, quit work,
income changed; for example, wages,
(Show the dates you received any new income or
got raise, received inheritance)
city pension, etc.)
the date income changed)

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
SOURCE
CASH/NON-INTEREST-BEARING BANK ACCOUNTS

VETERAN
$

SPOUSE

CHILD:

$

$

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)
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. 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 past 12 months. DO NOT REPORT DEPENDENTS’
EXPENSES.

$

10. FAMILY MAINTENANCE (Hardship) EXPENSES FOR THE NEXT 12 MONTHS (Read Paragraph 8 of the EVR
Instructions). Complete ONLY IF VA is currently excluding children’s income on the grounds of hardship. Show
total family expenses expected for the next 12 months.

$

11A. SIGNATURE OF VETERAN (Read Paragraph 9 of the EVR Instructions before signing)

11B. DATE SIGNED

11C. 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.