VA Form 21-0519s Improved Pension Eligibility Verification Report - Survi

OMB Approved No. 2900-0101
Respondent Burden : 40 minutes
VA REGIONAL OFFICE

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(SURVIVING SPOUSE WITH CHILDREN) 9S
VA FILE NUMBER - PAYEE NUMBER - STUB NAME
PAYEE ADDRESS
VA REGIONAL OFFICE RETURN ADDRESS

IF YOU DO NOT RETURN THE COMPLETED FORM TO VA BY

YOUR BENEFITS WILL BE DISCONTINUED.

IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER (Enter correct number if
wrong or missing)

1B. VETERAN’S SOCIAL SECURITY NUMBER (Enter correct number if
wrong or missing)

1C. ARE THE SOCIAL SECURITY NUMBERS SHOWN ABOVE CORRECT?

1D. YOUR DATE OF BIRTH (Month, Day, Year)

YES

NO

(If "NO," enter correct Social Security
Numbers in Item 1A and/or 1B)

2. MARITAL STATUS (Check only one box)
(1) I HAVE NOT MARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran’s death.)
(2)
(3)

I REMARRIED ON
(DATE) AND I AM STILL MARRIED (You married after the veteran’s death
and you are currently married. Enter the date you married your current spouse.)
I REMARRIED AFTER THE VETERAN DIED BUT THE MARRIAGE ENDED BY DEATH OR DIVORCE ON

(DATE)

(You remarried but you are not currently married. Show the date your latest marriage ended.)
3A. UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions)
PLEASE CHECK ONE (X)
FULL NAME OF EACH
DATE OF
SOCIAL SECURITY
OVER 18 AND UNDER ANY AGE PERMANENTLY
CHILD
BIRTH
UNDER
18
NUMBER
23, AND ATTENDING HELPLESS FOR MENTAL
(First, middle initial, last)
(Mo., day, yr.)
YEARS OF AGE
SCHOOL

OR PHYSICAL REASONS

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

CHILD’S COMPLETE ADDRESS

4A. ARE YOU A PATIENT IN A NURSING HOME?

NAME OF PERSON CHILD LIVES
WITH (If Applicable)

MONTHLY AMOUNT YOU
CONTRIBUTE TO CHILD’S
SUPPORT

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

NO (If "YES," complete Items 4B through 4D. If "NO," go to Item 5.)
YES
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?

YES

NO

YES

NO

5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING

?

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)

21-0519S

SUPERSEDES VA FORM 21-0519S, SEP 1996, 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

SURVIVING SPOUSE

CHILD:

CHILD:

SOCIAL SECURITY
(See Note Below)
U.S. CIVIL SERVICE

$

$

$

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

NOTE: If an amount is preprinted in one or more of the Social Security blocks above and the amount is correct, you are not required to make any entry
in that Social Security block. Read Paragraph 3 of the EVR Instructions.
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.
SURVIVING SPOUSE

CHILD:

CHILD:

SOURCE
GROSS WAGES FROM ALL
EMPLOYMENT

$

$

$

$

$

$

TOTAL INTEREST
AND DIVIDENDS
ALL OTHER (Show Source)

ALL OTHER (Show Source)

7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING
? (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.)
7D. WHAT INCOME CHANGED? (Show what
7E. WHEN DID THE INCOME CHANGE?
income changed, for example, wages,
(Showthe dates you received any
city pension, etc.)
newincome or the date income changed)

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

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

SURVIVING SPOUSE

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

CHILD:

$

CHILD:

$

$

IRA’S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY
8. FAMILY MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)
A. Our records show that during
you paid unreimbursed medical expenses of $
.
(MAKE NO ENTRY ON THIS LINE. GO DIRECTLY TO 8D IF $0 APPEARS IN 8A, OTHERWISE GO TO 8B.)
B. Enter the amount of unreimbursed medical expenses you paid during

.$

C. Enter the amount of unreimbursed medical expenses you will pay during
.$
D. If an amount greater than $0 is printed in 8A and you entered amounts in 8B and 8C which are substantially the same as the
amount printed in 8A, you do not have to complete the VA Form 21-8416 that was sent to you with this EVR. However, you
may be required to complete VA Form 21-8416 and furnish proof of payments at a later date. If $0 is printed in Item 8A or
if an amount is printed in 8A but it is not substantially the same as the amounts you entered in 8B and 8C, you must submit VA Form 21-8416 with this EVR
in order to claim a medical expense deduction or continue an existing deduction.
9. SURVIVING SPOUSE’S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR Instructions)
Show amounts paid by you during

. DO NOT REPORT CHILDREN’S EXPENSES. $

10. FAMILY MAINTENANCE (HARDSHIP) EXPENSES FOR

. (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
. $
11A. SIGNATURE OF PAYEE (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.