Form 21P-8049 REQUEST FOR DETAILS OF EXPENSES

OMB Approved No. 2900-0138
Respondent Burden: 15 minutes
Expiration Date: XXXXXXX

REQUEST FOR DETAILS OF EXPENSES
INSTRUCTIONS - We need additional information to determine whether you are entitled to benefits. Please complete all items. If an answer is
"none" or "0" write that. For additional space, use Item 12, "Remarks," or attach a separate sheet indicating the item number to which the answers
apply. If you have any questions or need assistance, please call 1-877-294-6380 (Hearing Impaired TDD line 711).
1. NAME AND ADDRESS OF CLAIMANT

2. NAME OF VETERAN (First-middle-last)

3. VA FILE NUMBER

SECTION I - DEPENDENTS NOT LIVING WITH YOU

(List ONLY persons you support who DO NOT live with you)
4A. NAME

4B. AGE

4C. RELATIONSHIP

4D. AMOUNT YOU CONTRIBUTE TO SUPPORT
$
$
$
$
$

SECTION II - DEPENDENTS LIVING WITH YOU

(List ONLY persons you support who DO live with you)
5A. NAME

5B. AGE

5C. RELATIONSHIP

SECTION III - MONTHLY EXPENSES (EXCEPT MEDICAL)
FOR YOU AND THOSE LISTED ABOVE AS LIVING WITH YOU
6A. ITEM (Cont'd)

6B. AMOUNT

6A. ITEM

6B. AMOUNT(Cont'd)

HOUSING

$

UTILITIES

$

FOOD

$

EDUCATION OF CHILDREN

$

TAXES

$

OTHER
(Specify)

$

INTEREST

$

$

CLOTHING

$

$

VA FORM
XXXX

21P-8049

EXISTING STOCK OF VA FORM 21-8049, AUG 2007,
WILL BE USED.

SECTION IV - HOSPITAL AND MEDICAL EXPENSES
7A. DO YOU HAVE OR EXPECT TO HAVE ANY LARGE OR UNUSUAL HOSPITAL OR MEDICAL EXPENSES FOR YOURSELF
AND OTHERS YOU SUPPORT AND LIVE WITH?
YES

NO

7B. ESTIMATED COST PER YEAR
$

7C. EXPLANATION

SECTION V - EDUCATIONAL EXPENSES
8. DO YOU EXPECT TO MAKE PROVISIONS FOR YOUR CHILDREN'S EDUCATIONAL NEEDS, INCLUDING ADVANCED TECHNICAL OR COLLEGE EDUCATION?
YES

NO

SECTION VI - EXPENSES OF LAST ILLNESS AND BURIAL OF VETERAN, SPOUSE, OR CHILD
AND JUST DEBTS OF DECEASED VETERAN OR PARENT'S SPOUSE
9B. RELATIONSHIP TO YOU
9C. DATE OF DEATH
9A. NAME OF DECEASED PERSON (First-middle-last)
SPOUSE

CHILD

PARENT

EXPENDITURES FOR ABOVE-NAMED PERSON
NOTE - Furnish information concerning unreimbursed expense as follows:
A VETERAN - For his/her spouse's or child's last illness and burial.
A CHILD - For veteran's last illness, burial and just debts.
A PARENT - For his/her spouse's or veteran's last illness and burial
and for his/her spouse's just debts.
10A. NAME AND ADDRESS OF
PERSON TO WHOM PAID

10B. NATURE OF
EXPENSES OR DEBT

A SPOUSE - For the last illness and burial of veteran's child.
A WIDOW(ER) - For veteran's last illness, (paid before or after
the veteran's death), burial and just debts and for the last illness
and burial of veteran's child.
10C. TOTAL AMOUNT
OF EXPENSES OR DEBT

10D. AMOUNT
PAID BY YOU

$

$

$

$

$

$

$

$

10E. DATE
PAID

SECTION VII - COMMERCIAL LIFE INSURANCE PAYMENTS
NOTE: Under Public Law 108-454, VA may not count as income the lump sum proceeds of a life insurance policy on a
veteran who dies after December 9, 2004. Proceeds from all other insurance payments may be countable.
11A.
11B.
11C.

TOTAL RECEIVED OR EXPECTED BY CLAIMANT

AMOUNT
$

EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments, explain payment schedule in

Item 12, Remarks)

NAME OF THE DECEASED FOR WHOM PAYMENT IS RECEIVED.

12. REMARKS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission or any statement or evidence of a material fact,
knowing it to be false.
I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
14. DATE
13. SIGNATURE OF CLAIMANT (Do not print, sign in ink)
15. TELEPHONE NUMBER(S) (Include Area Code)
A. DAYTIME

B. EVENING

Privacy Act Information: The 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 38, Code of
Federal Regulations 1.576 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, Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation
to respond is required to obtain or retain benefits. The requested information is considered relevant and necessary to determine entitlement to benefits. The responses you submit are considered
confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. You are required to provide the Social Security
number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may disclose them for purposes stated above.
Respondent Burden: We need this information to determine entitlement to pension or parent's dependency and indemnity compensation (38 U.S.C. 1503 and 1315). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 15 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 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.
VA FORM 21P-8049, XXXX