VA Form 21-0518 Improved Pension Eligibility Report - Surviving Spouse W

OMB Approved No. 2900-0101
Respondent Burden : 30 minutes
VA REGIONAL OFFICE

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(SURVIVING SPOUSE WITH NO CHILDREN)
VA FILE NUMBER - PAYEE NUMBER - STUB NAME

8

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 (Mo., day, yr.)

YES

NO

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

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

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.)

(3)

I REMARRIED AFTER THE VETERAN DIED BUT THE MARRIAGE ENDED BY DEATH OR DIVORCE ON
remarried but you are not currently married. Show the date your latest marriage ended.)

.

(You

3. NUMBER OF UNMARRIED, DEPENDENT CHILDREN (See Paragraph 1 of the EVR Instructions)

IN YOUR CUSTODY
AMOUNT CONTRIBUTED DURING

NOT IN YOUR CUSTODY
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?
NO
YES
5. DID YOU RECEIVE ANY WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING

?

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)

21-0518

SUPERSEDES VA FORM 21-0518, JUL 1995, WHICH WILL
NOT BE USED.

(Continued on Reverse)

7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
If no income or net worth was received from a particular source, write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
SOURCE

SURVIVING SPOUSE

SOCIAL SECURITY
(See Note Below)

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
OTHER (Show Source)
OTHER (Show Source)
NOTE -If an amount is preprinted in the Social Security block above and that amount is correct, you are not required to make
any entry in the Social Security block. Please 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.
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
income changed; for example, wages,
city pension, etc.)

7E. WHEN DID THE INCOME CHANGE?
(Show the dates you received any new
income or the date income changed)

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

SURVIVING SPOUSE
$

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 EVR Instructions). Show amounts paid by you during
CHILDRENS’ EXPENSES.

. DO NOT REPORT
$

10A. SIGNATURE OF PAYEE (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.