VA Form 21-0517 Improved Pension Eligibility Verification Report - Veter

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

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(VETERAN WITH CHILDREN)
7
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)

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

YES

NO

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

1D. FIRST, MIDDLE, LAST NAME OF
SPOUSE

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

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

2. MARITAL STATUS (Check only one box)
MARRIED LIVING WITH SPOUSE (You are legally married and you live with your spouse or are separated
(1)
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
$
If you separated in
, show the date of separation
NOT MARRIED (You have never married or are now divorced or widowed.) If your marriage ended in
,
(3)
the date of divorce or death

show

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 ITEM 3A WHO DO NOT LIVE WITH YOU
NAME OF CHILD

CHILD’S COMPLETE ADDRESS

MONTHLY AMOUNT YOU
CONTRIBUTE TO CHILD’S
SUPPORT

NAME OF PERSON CHILD LIVES
WITH (If Applicable)

$
$
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

?

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

SUPERSEDES VA FORM 21-0517, OCT 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

VETERAN

SPOUSE

CHILD:

SOCIAL SECURITY(See Note below)
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
MILITARY 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 the 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
VETERAN

SPOUSE

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 new
city pension, etc.)
income 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
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)
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. VETERAN’S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of
the EVR Instructions). Show amounts paid by you during
. DO NOT REPORT DEPENDENTS’ 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 during
.
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.