VA Form 21P-0784 Supplemental Income Questionnaire (Philippine Claims Onl

SUPPLEMENTAL INCOME QUESTIONNAIRE
(For Philippine Claims Only)

OMB Approved No. 2900-0668
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

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 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, 58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and Employment 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 maximum benefits under the law. 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.
Respondent Burden: We need this information to determine eligibility for pension benefits (38 U.S.C. 1521, 1541, and 1542).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
comment or suggestions about this form.
INSTRUCTIONS: Before further action can be taken on your claim for pension, we need more information about your income from other sources. Your answer to every question is
important to help us complete your claim. Please answer all questions fully and accurately, and print clearly. If an answer is "None" or "0," write that, DO NOT LEAVE ANY QUESTIONS
BLANK. Specify whether amounts are in dollars or pesos.
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

2. VA FILE NUMBER

3. FIRST NAME - MIDDLE NAME - LAST NAME OF CLAIMANT
(If other than veteran)

PART I - SOURCES OF INCOME

NOTE: Be sure to report in Part II the amounts of income received for any items marked "Yes."
DO YOU OR YOUR DEPENDENTS:

YES

NO

4. OPERATE A SARI-SARI STORE?
5. ENGAGE IN A BUY-AND-SELL BUSINESS?
6. OWN A FISHING BOAT?
7. IF YOU ANSWERED "YES" TO ITEM 6, DO YOU OR YOUR DEPENDENTS:
a. Sell part of the catch?
b. Receive part of the catch as rent?
8. OWN FARM LANDS AND SELL THE PRODUCE, FRUITS, VEGETABLES, RICE, CORN, COCONUT, NIPA, BURI RATTAN, BAMBOO,
ANIMALS, ETC.?
9. IF YOU ANSWERED "YES" TO ITEM 8, DO YOU OR YOUR DEPENDENTS:
a. Receive cash for your share of the produce?
b. Receive part of the crop as your share?
10. RENT OUT ANY PART OR YOUR HOME OR APARTMENT?
11. OWN STOCKS?
12. HAVE A SAVINGS ACCOUNT?
13. HAVE SAVINGS CERTIFICATES?
14. HAVE GOVERNMENT (TREASURY) BONDS?

PART II - INCOME RECEIVED DURING THE LAST 12 MONTHS
MONTHLY INCOME (Tell us about the income you and your dependents receive every month)

SOURCES OF INCOME

VETERAN

SPOUSE
OR
WIDOW

CHILD

CHILD

15. U.S. SOCIAL SECURITY
16. U.S. CIVIL SERVICE
17. MILITARY RETIRED PAY/SURVIVORS BENEFIT PLAN ANNUITY (SBP)
18. OTHER RETIREMENT BENEFITS (Please write in the source below, (i.e., Philippine Government
Retirement, GSIS Retirement, Philippine Social Security, PVAO Annuities))
A.
B.
C.
D.
OTHER INCOME (Tell us about the other income you and your dependents receive)
19. GROSS WAGES AND SALARY
20. TOTAL INTEREST AND DIVIDENDS RECEIVED ON SAVINGS ACCOUNTS, TIME DEPOSITS,
STOCKS, AND BONDS, ETC.
21. INCOME FROM RENTAL OF HOUSE OR APARTMENT
22. INCOME FROM RENTAL OF FARM OR RICE LAND (Give the peso equivalent of farm products
received)
VA FORM
XXX XXXX

21P-0784

SUPERSEDES VA FORM 21-0784, MAR 2018,
WHICH WILL NOT BE USED.

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OTHER INCOME (Tell us about the other income you and your dependents receive) (Continued)

SOURCES OF INCOME

VETERAN

SPOUSE
OR
WIDOW

CHILD

CHILD

VETERAN

SPOUSE
OR
WIDOW

CHILD

CHILD

23. INCOME FROM FARM (Please write in the type of products below, (i.e., palay, corn, coconut, copra,
coffee, fruits, vegetables, etc., and give the peso equivalent of farm products generated))

24. INCOME FROM BUSINESS
25. CONTRIBUTIONS FROM CHILDREN WHO ARE NOT YOUR DEPENDENTS
26. OTHER INCOME (Please write in the source of income below)
27. OTHER INCOME (Please write in the source of income below)

PART III - NET WORTH
SOURCE OF INCOME
28. CASH, BANK SAVINGS ACCOUNTS
29. TIME DEPOSITS IN BANK
30. STOCKS AND BONDS
31. VALUE OF BUSINESS ASSETS AND INVESTMENTS
32. MARKET VALUE OF FARM
33. MARKET VALUE OF APARTMENT AND OTHER PROPERTIES (Not your home unless part of it is
rented)
34. REMARKS (If any)

CERTIFICATION

I CERTIFY THAT the statements in this document are true and complete to the best of my knowledge.
35A. SIGNATURE OF CLAIMANT (If claimant can write, the he or she must sign their name. If claimant cannot write, then affix a
thumbprint which must be witnessed by two persons who can write) (Sign in ink)

35B. DATE SIGNED

WITNESSES TO SIGNATURE IF MADE BY THUMBPRINT
36A. SIGNATURE OF WITNESS (If claimant signed above by thumbprint) (Sign in ink)

37A. SIGNATURE OF WITNESS (If claimant signed above by thumbprint) (Sign in ink)

36B. PRINT NAME AND ADDRESS OF WITNESS

37B. PRINT NAME AND ADDRESS OF WITNESS

38. PRINT NAME AND ADDRESS OF PERSON WHO HELPED YOU COMPLETE THIS FORM (If applicable)

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-0784, XXX XXXX

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