VA Form 21P-0517-1 Improved Pension Eligibility Verification Report (Vetera

OMB Control No. 2900-0101
Respondent Burden: 40 minutes
Expiration Date: xxxxxxxxxxxx

FIRST, MIDDLE, LAST NAME OF VETERAN

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(VETERAN WITH CHILDREN)
YOUR COMPLETE MAILING ADDRESS

7

VA FILE NUMBER
VA REGIONAL OFFICE RETURN ADDRESS

IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER

1B. YOUR SPOUSE'S SOCIAL SECURITY NUMBER

1C. FIRST, MIDDLE, LAST NAME OF SPOUSE

1D. SPOUSE'S DATE OF BIRTH (Mo., day, yr.)

2. MARITAL STATUS (Check only one box)
MARRIED-LIVING WITH SPOUSE (You are legally married and you live with your spouse or are separated for

(1)

medical reasons.)
MARRIED-NOT LIVING WITH SPOUSE (You are legally married but separated from your spouse.) Show the amount

(2)

you contributed to your spouse's support during the past 12 months

.

$

If you separated within the last 12 months, show the date of separation

.

NOT MARRIED (You have never married or are now divorced or widowed.) If your marriage ended within the last 12 months,

(3)

show the date of divorce or death

.

3A. UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions, VA Form 21P-0510)
FULL NAME OF EACH CHILD

(First, middle initial, last)

DATE OF BIRTH

(Mo., day, yr.)

SOCIAL SECURITY
NUMBER

PLEASE CHECK ONE (X)
UNDER 18 OVER 18 AND UNDER ANY AGE PERMANENTLY
YEARS OF 23, AND ATTENDING HELPLESS FOR MENTAL
AGE
SCHOOL
OR PHYSICAL REASONS

3B. UNMARRIED DEPENDENT CHILDREN LISTED IN ITEM 3A WHO DO NOT LIVE WITH YOU
NAME OF PERSON
CHILD'S COMPLETE
NAME OF EACH CHILD
CHILD LIVES WITH
ADDRESS
(If Applicable)

MONTHLY AMOUNT
YOU CONTRIBUTE TO
CHILD'S SUPPORT
$
$
$

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

NO

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

(If "Yes," Complete Items 4B thru 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?
YES

NO

5. DID EITHER YOU OR YOUR SPOUSE RECEIVE ANY WAGES OR WERE EITHER OF YOU EMPLOYED AT ANY TIME DURING THE
PAST 12 MONTHS?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
YES
VA FORM
XXX 2014

NO

(If "Yes," write in the VA file number of the other benefit.)

21P-0517-1

SUPERSEDES VA FORM 21-0517-1, FEB 2012,
WHICH WILL NOT BE USED.

Page 1

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." VA WILL INTERPRET A BLANK SPACE AS "NONE" or "0.")

SOURCE

VETERAN

SOCIAL SECURITY

SPOUSE

CHILD:

$

$

$

U. S. CIVIL SERVICE
U. S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
MILITARY RETIREMENT
OTHER (Show Source)
OTHER (Show Source)
OTHER (Show Source)
7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
NOTE: Report annual income for the dates indicated. If no dates are shown above the columns that follow, then report last calendar year (January
through December) income in the left-hand column and current calendar year income in the right-hand column.
If no income was received from a particular source, write "0" or "none". VA WILL INTERPRET A BLANK SPACE AS "NONE" or "0."
SPOUSE

VETERAN
SOURCE

CHILD:

FROM:

FROM:

FROM:

FROM:

FROM:

FROM:

THRU:

THRU:

THRU:

THRU:

THRU:

THRU:

$

$

$

$

$

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 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)
(If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)
YES
NO
7D. WHAT INCOME CHANGED? (Show what
7E. WHEN DID THE INCOME CHANGE? (Show 7F. HOW DID INCOME CHANGE? (Explain what
income changed, for example, wages, city
the dates you received any new income or the
happened; for example, quit work, got raise,
pension, etc.)
date income changed)
received inheritance)

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

VETERAN

CASH/NON- INTEREST-BEARING BANK ACCOUNTS

$

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)
If you are using this form as your annual Eligibility Verification Report and Paragraph 6 of the EVR Instructions indicates that you should report medical
expenses, use VA Form 21P-8416, Medical Expense Report. If you are using this form as a supplement to a pending claim, you do not need to report
medical expenses. If entitlement is established, you will have an opportunity to report your medical expenses at the end of the year.
9. VETERAN'S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR
$
Instructions) Show amounts paid by you during the past 12 months. DO NOT REPORT DEPENDENTS' EXPENSES.
10. FAMILY MAINTENANCE (Hardship) EXPENSES FOR THE NEXT 12 MONTHS (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 the next 12 months.
11A. SIGNATURE OF VETERAN (Read paragraph 9 of the EVR Instructions before signing)

DAYTIME

$

11B. DATE SIGNED

11C. TELEPHONE NUMBERS (Include Area Code)
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-0517-1, XXX 2014

Page 2