VA Form 21P-0513-1 Old Law and Section 306 Eligibility Verification Report

OMB Control No. 2900-0101
Respondent Burden: 30 minutes
Expiration Date: XXXXXXXX
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN
VETERAN'S SOCIAL SECURITY NUMBER

OLD LAW AND SECTION 306
ELIGIBILITY VERIFICATION REPORT
3
(CHILDREN ONLY)

NAME OF CHILD'S CUSTODIAN

VA FILE NUMBER
COMPLETE MAILING ADDRESS OF CHILD OR CUSTODIAN

VA REGIONAL OFFICE RETURN ADDRESS

IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21P-0510) before completing this form. This form is used by children and
custodians of children receiving Old Law or Section 306 Pension. If you have been receiving a fixed rate of pension since 1960, you receive Old Law
Pension. If you have been receiving a fixed rate of pension since 1978, you receive Section 306 pension. If you receive Old Law Pension, do not
complete Item 2G, Net Worth, and Item 3, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1. CHILD(REN)'S MARITAL AND SCHOOL STATUS

List the children's names, dates of birth, and Social Security numbers, and indicate marital and school status for all children being paid on
this award. If the child does not have a Social Security number, write "No SSN" in the space provided for the child's Social Security
number. If other children are on separate VA awards, they will receive their own EVRs. If additional space is needed, attach a separate
sheet of paper.
NOTE: Complete Item 1E only if the child is 18 years of age or older. Complete Item 1F only if the child is between the ages of 18 and
23 and has not been rated disabled by VA. The child is considered to have attended school continuously if the child attended every
regular school term except summer school or holiday periods. If Block (2), STOPPED SCHOOL, is checked in Item 1E or "NO" is
checked in Item 1F, provide the date the child last attended school in Item 1F.
A. FULL NAME OF CHILD

(First, middle, initial, last)

B. DATE OF
BIRTH

(Mo., day, yr.)

C. SOCIAL
SECURITY
NUMBER

D. MARITAL STATUS
(1)

F. ATTENDED SCHOOL
CONTINUOUSLY SINCE
AGE 18
DATE LEFT
ATTENDS SCHOOL
SCHOOL
STOPPED SCHOOL
YES

E. SCHOOL STATUS

MARRIED

(1)

(3)

DIVORCED/WIDOWED (2)
(3)
NEVER MARRIED

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED (2)
(3)
NEVER MARRIED

STOPPED SCHOOL

YES

(3)

DISABLED CHILD

NO

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED (2)
(3)
NEVER MARRIED

STOPPED SCHOOL

YES

(3)

DISABLED CHILD

NO

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DISABLED CHILD

NO

(3)

DIVORCED/WIDOWED (2)
(3)
NEVER MARRIED

(1)

MARRIED

(1)

ATTENDS SCHOOL

(2)

DIVORCED/WIDOWED (2)

STOPPED SCHOOL

YES

(3)

NEVER MARRIED

DISABLED CHILD

NO

(2)

(3)

STOPPED SCHOOL

YES

DISABLED CHILD

NO

DATE LEFT
SCHOOL

DATE LEFT
SCHOOL

DATE LEFT
SCHOOL

DATE LEFT
SCHOOL

2. REPORT OF INCOME AND NET WORTH
NOTE: If no income was received from a particular source, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
SOURCE
SOCIAL SECURITY

CHILD'S NAME:

CHILD'S NAME:

CHILD'S NAME:

$

$

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY
INCOME (SSI)
OTHER INCOME (Show source)
OTHER INCOME (Show source)
VA FORM
XXX 2014

21P-0513-1

SUPERSEDES VA FORM 21-0513-1, JUN 2004,
WHICH WILL NOT BE USED.

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2B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
If no income was received, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
CHILD
SOURCE

GROSS SALARY OR
WAGES

CHILD

CHILD

FROM:

FROM:

FROM:

FROM:

FROM:

FROM:

THRU:

THRU:

THRU:

THRU:

THRU:

THRU:

$

$

$

$

$

$

TOTAL INTEREST AND
DIVIDENDS
ALL OTHER (Show Source)
ALL OTHER (Show Source)
2C. 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)

(1)

YES

(2)

NO

(If "YES", complete Items 2D through 2F. If "NO", go to Item 2G.)

2D. WHAT INCOME CHANGED?

2E. WHEN DID INCOME CHANGE?
(Show the dates you received any new income

(Show what income changed; for
example, wages, city pension, etc.)

or the date income changed)

2F. HOW DID INCOME CHANGE?

(Explain what happened; for example,
quit work, got raise, received inheritance)

2G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
NOTE: Complete only if you receive Section 306 Pension. Skip to Item 4A if you receive Old Law Pension.
SOURCE
CASH, NON-INTEREST-BEARING BANK
ACCOUNTS

CHILD

CHILD

CHILD

$

$

$

INTEREST-BEARING BANK ACCOUNTS

STOCKS, BONDS, MUTUAL FUNDS, ETC.

CERTIFICATES OF DEPOSIT, IRAs, ETC.

REAL PROPERTY (Excluding child's home)

ALL OTHER PROPERTY

3. CHILD'S MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)
NOTE: Skip to Item 4A if you receive Old Law Pension.

If Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21P-8416, Medical Expense
Report, to report your medical expenses.
4A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

A. DAYTIME

4B. DATE

5. TELEPHONE NUMBERS (Include Area Code)
B. 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.
VA FORM 21P-0513-1, JUN 2014

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