Form 21P-4165 Pension Claim Questionnaire for Farm Income

OMB Approved No. 2900-0095
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

PENSION CLAIM QUESTIONNAIRE
FOR FARM INCOME
INSTRUCTIONS: Before further action can be taken on your claim, we must have more information
concerning your farming activity. Please answer all questions on this form accurately and completely. If the
answer to a particular question is none, write "NONE" in the space provided. Please read the Privacy Act and
Respondent Burden Information on Page 3 before completing this form.
References in this form to "THIS YEAR" refer to the
period. (If blank, "THIS YEAR" refers to the current
calendar year. References to "LAST YEAR" refer to
the 12 month period preceding "THIS YEAR".)

1. PERIOD STARTING DATE
Month

Day

2. PERIOD ENDING DATE
Year

Month

Day

Year

SECTION I: VETERAN AND CLAIMANT INFORMATION

3. VETERAN'S NAME (First, Middle Initial, Last)

5. VETERAN'S FILE NUMBER

4. VETERAN'S SOCIAL SECURITY NUMBER

6. CLAIMANT'S NAME (If claimant is not the veteran - First, Middle Initial, Last)

8. CLAIMANT'S DATE OF BIRTH (MM,DD,YYYY)

7. CLAIMANT'S SOCIAL SECURITY NUMBER

Month

Day

Year

9. CLAIMAINT'S CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City
Country

State/Province

ZIP Code/Postal Code

10. CLAIMANT'S TELEPHONE NUMBER (Include Area Code) 11. CLAIMANT E-MAIL ADDRESS

SECTION II: REPORT OF THE TOTAL OF ALL GROSS RECEIPTS

(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, etc.)
12. AMOUNT RECEIVED LAST YEAR
$

13. AMOUNT EXPECTED THIS YEAR
$

14. AMOUNT ANTICIPATED NEXT YEAR
$

15. NAME(S) OF OWNER(S) OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH (As shown by deed, trust or other document)
A. NAME OF OWNER OF BUSINESS

VA FORM
XXX XXXX

21P-4165

SUPERSEDES VA FORM 21-4165, DEC 2019,
WHICH WILL NOT BE USED.

B. DEGREE OF OWNERSHIP

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SECTION III: FARM OPERATING EXPENSES

(Include landlord's share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)
16. FARM OPERATING EXPENSE
A. HIRED LABOR

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

B. FEEDS PURCHASED

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

C. SUPPLIES PURCHASED

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

D. MACHINE HIRE

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

E. REPAIRS AND MAINTENANCE OF FARM
BUILDINGS AND MACHINERY (Except dwellings)

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

F. CASH RENT

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

G. PROPERTY TAXES

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

H. INSURANCE ON PROPERTY

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

I. INTEREST ON MORTGAGE AND OTHER LOANS

(Not payment on principal)

$

17. TOTAL EXPENSES

$

18A. PROVIDE THE TOTAL ACREAGE OWNED BY YOU

18B. IS YOUR PRIMARY RESIDENCE LOCATED ON THE ACREAGE YOU OWN?

18C. HOW MANY OF THE ACRES YOU OWN ARE CONSIDERED
PART OF YOUR PRIMARY RESIDENCE?

18D. WHAT IS THE SPECIFIC VALUE OF THE ACREAGE RELATED TO YOUR
PRIMARY RESIDENCE?

YES

NO

(If "Yes", complete Items 18C and 18D)

$

19. ACREAGE IN CROPS AND PASTURE
(A) KIND

(Grain, hay, cotton, tobacco, etc.)

20. LIVESTOCK INFORMATION

NUMBER OF ACRES
(B) LAST YEAR

(C) THIS YEAR

(A) KIND

(Cattle, pigs, sheep, ducks, etc.)

(B) TOTAL NUMBER
ON FARM NOW

PASTURE
21. DO YOU RENT YOUR FARM TO OR FROM SOMEONE ELSE?
YES

NO

(If "Yes", furnish a copy of your farm rental agreement or lease or a statement setting forth in detail particulars of the agreement)

22. REMARKS (If any)

VA FORM 21P-4165, XXX XXXX

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22. REMARKS (If any - continued)

SECTION IV: CERTIFICATION AND SIGNATURE OF CLAIMANT

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
23A. SIGNATURE OF CLAIMANT (Sign in ink)

23B. DATE SIGNED

SECTION V: WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK
Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and addresses of such
witnesses must be shown below.
24A. SIGNATURE OF WITNESS (Sign in ink)

24B. PRINTED NAME AND ADDRESS OF WITNESS

25A. SIGNATURE OF WITNESS (Sign in ink)

25B. PRINTED NAME AND ADDRESS OF WITNESS

FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged,
allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under
laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has
issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.
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 5, Code of Federal
Regulations 1.526 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 and Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your response is required to obtain or retain benefits. 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 the purposed stated above. Information that you furnish may be utilized in computer matching programs
with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your
participation in any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: We need this information to determine eligibility for disability pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1521, death pension under 38 U.S.C.
1315, death compensation under 38 U.S.C. 1121, or Parents' dependency and indemnity compensation under 38 U.S.C. 1315. We estimate that you will need an average of 30 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-4165, XXX XXXX

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