VA Form 21P-0519S- Improved Pension Eligibility Verification Report (Surviv

OMB Approved No. 2900-0101
Respondent Burden : 40 minutes
Expiration Date: XXXXXXXX

FIRST, MIDDLE, LAST NAME OF VETERAN

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(Surviving Spouse with Children)

FIRST , MIDDLE, LAST NAME OF SURVIVING SPOUSE
COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE

9S

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. VETERAN'S SOCIAL SECURITY NUMBER

1C. YOUR DATE OF BIRTH (Month, Day, Year)

2. MARITAL STATUS (Check only one box)
(1)

I HAVE NOT MARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran's death.)

(2)

I REMARRIED ON (DATE)

AND I AM STILL MARRIED (You married after the veteran's death and you are currently married.

Enter the day you married your current spouse.)
(3)

I REMARRIED AFTER THE VETERAN DIED BUT THE MARRIAGE ENDED BY DEATH OR DIVORCE ON

(DATE).

(You remarried but you are not currently married. Show the date your latest marriage ended.)

3A. UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions)
PLEASE CHECK ONE (X)
FULL NAME OF EACH
CHILD
(First, middle initial, last)

DATE OF
BIRTH
(Mo., day, yr.)

SOCIAL SECURITY
NUMBER

UNDER 18
YEARS OF AGE

OVER 18 AND
UNDER 23, AND
ATTENDING
SCHOOL

ANY AGE
PERMANENTLY
HELPLESS FOR
MENTAL OR
PHYSICAL REASONS

3B. UNMARRIED DEPENDENT CHILDREN LISTED IN 3A WHO DO NOT LIVE WITH YOU
NAME OF CHILD

CHILD'S COMPLETE ADDRESS

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

NO (If "YES," complete Items 4B through 4D. If "NO," go to Item 5.)

NAME OF PERSON CHILD
LIVES WITH (If Applicable)

MONTHLY AMOUNT YOU
CONTRIBUTE TO CHILD'S
SUPPORT

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

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 YOU RECEIVE WAGES OR WERE 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
NO (If "YES," write in the VA file number of the other benefit)

VA FORM
XXX 2014

21P-0519S-1

SUPERSEDES VA FORM 21-0519S-1, FEB 2012,
WHICH WILL NOT BE USED.

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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

SURVIVING SPOUSE

CHILD:

CHILD:

SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
OTHER RETIREMENT
OTHER (Show Source)
OTHER (Show Source)
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." VA WILL INTERPRET A BLANK SPACE AS "NONE" OR "0."
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.
CHILD:
CHILD:
SURVIVING SPOUSE
SOURCE
FROM:
FROM:
FROM:
FROM:
FROM:
FROM:
THRU:

THRU:

THRU:

THRU:

THRU:

THRU:

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

SOURCE

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
CHILD:
SURVIVING SPOUSE

CHILD:

CASH/NON-INTEREST-BEARING BANK ACCOUNTS
INTEREST-BEARING BANK ACCOUNTS
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)
Normally, medical expenses are reported at the end of the year. 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. SURVIVING SPOUSE'S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR Instructions)
Show amounts paid by you during the last 12 months. DO NOT REPORT CHILDRENS' EXPENSES.

$

10. FAMILY MAINTENANCE (HARDSHIP) EXPENSES FOR 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 PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

DAYTIME

11B. DATE

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.
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VA FORM 21P-0519S-1, XXX 2014