Form VA Form 21P-4165 VA Form 21P-4165 Pension Claim Questionnaire for Farm Income

OMB Approved No. 2900-0095
Respondent Burden: 30 minutes

PENSION CLAIM QUESTIONNAIRE
FOR FARM INCOME

1. VA FILE NUMBER
C/SS-

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of Federal
Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States,
litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status and personnel administration)
as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register.
Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101
(c) (1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and
still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA
benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine eligibility for disability pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1521, death pension under 38 U.S.C.
1315, or death compensation under 38 U.S.C. 1121. We estimate that you will need an average 30 minutes to review the instructions, find the information and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed.
Valid OMB control numbers can be located on the OMB Internet Page at http:www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to
send comments or suggestions about this form.

INSTRUCTIONS: Before further action can be taken on your claim, we must have more information concerning your farming activity. Please answer all questions on
this form accurately and completely. If the answer to a particular question is none, write "NONE" in the space provided.
References in this form to "THIS YEAR" refer to the period
(If blank, "THIS YEAR" refers to the current calendar year. References
to "LAST YEAR" refer to the 12 month period preceding "THIS YEAR".)
2. FIRST - MIDDLE - LAST NAME OF VETERAN

PERIOD STARTING DATE

3. SOCIAL SECURITY NUMBER

PERIOD ENDING DATE

4. VA OFFICE AND ADDRESS

5. REPORT OF THE TOTAL OF ALL GROSS RECEIPTS

(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, etc.)
A. AMOUNT RECEIVED LAST YEAR

B. AMOUNT EXPECTED THIS YEAR

C. AMOUNT ANTICIPATED NEXT YEAR

$

$

$

6. NAMES OF OWNERS OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH

(As shown by deed, trust or other document)

7. FARM OPERATING EXPENSES
(Include landlord's share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)
AMOUNT
AMOUNT TO
AMOUNT
AMOUNT TO
ITEM
ITEM
SPENT LAST
BE SPENT
SPENT LAST
BE SPENT
YEAR
THIS YEAR
(A)
(D)
YEAR
THIS YEAR
(B)
(C)
(E)
(F)
OTHER EXPENSES (List)

HIRED LABOR

FEEDS PURCHASED
SUPPLIES PURCHASED
MACHINE HIRE
REPAIRS AND MAINTENANCE
OF FARM BUILDINGS AND
MACHINERY (Except dwellings)
CASH RENT
PROPERTY TAXES
INSURANCE ON PROPERTY
INTEREST ON MORTGAGE
AND OTHER LOANS

(Not payment on principal)

VA FORM
JUN 2013

21P-4165

TOTAL EXPENSES
EXISTING STOCKS OF VA FORM 21-4165, DEC 2010,
WILL BE USED.

(Cols. B and E)
$

(Cols. C and F)
$

8A. TOTAL ACREAGE OWNED BY
YOU

8B. ACREAGE RENTED TO OTHERS

8C. ACREAGE RENTED FROM
OTHERS

9. ACREAGE IN CROPS AND PASTURE
(Grain, hay, cotton, tobacco, etc.)

10. LIVESTOCK INFORMATION

NUMBER OF ACRES

KIND

LAST YEAR

8D. TOTAL ACREAGE OPERATED BY YOU

TOTAL NUMBER
ON FARM NOW

KIND

(Cattle, pigs, sheep, ducks, etc.)

THIS YEAR

PASTURE

11. TOTAL FARM WORK

(Furnish the following information about the work done by you, hired help and others)
YEAR
(A)

LINE
NO.

LAST
YEAR

THIS
YEAR

PROPORTION (Check applicable boxes)
(C)

ITEM
(B)

NONE

1

PROPORTION DONE BY YOU

2

PROPORTION DONE BY HIRED HELP

3

PROPORTION DONE BY OTHERS
(Including members of the family)

4

PROPORTION BEING DONE BY YOU

5

PROPORTION BEING DONE BY HIRED HELP

6

PROPORTION BEING DONE BY OTHERS
(Including members of the family)

1/4

1/2

3/4

ALL

12. PLEASE DESCRIBE ANY WORK YOU HAVE DONE FOR OTHERS DURING THE PAST YEAR AND THE AMOUNT OF SALARY OR WAGES YOU RECEIVED

13. DO YOU RENT YOUR FARM TO OR FROM SOMEONE ELSE?
YES

NO

(If "Yes", furnish a copy of your farm rental agreement or lease or a statement setting forth in detail particulars of the agreement)

14. DO YOU RECEIVE INCOME FROM ANY SOURCE OTHER THAN FARMING?
YES

NO

(If "Yes", explain fully, including income received)

CERTIFICATION AND SIGNATURE OF CLAIMANT

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15A. DATE SIGNED

15B. SIGNATURE OF CLAIMANT

15C. DAYTIME PHONE NO. (Including Area Code)

16. ADDRESS

15D. EVENING PHONE NO. (Including Area Code)

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK

Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and
addresses of such witnesses must be shown below.
17A. SIGNATURE OF WITNESS

17B. PRINTED NAME AND ADDRESS OF WITNESS

18A. SIGNATURE OF WITNESS

18B. PRINTED NAME AND ADDRESS OF WITNESS

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 to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21P-4165, JUN 2013