VA 21P-4185 Report of Income From Property or Business

OMB Control No. 2900-0108
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

REPORT OF INCOME FROM PROPERTY OR BUSINESS
PRIVACY ACT NOTICE: 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, 58VA21/22/28, Compensation,
Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your response is required to obtain or retain benefits. 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 2900-0108, and it expires XX/XX/20XX. Public reporting burden for this collection
of information is estimated to average 30 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this
collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to
OMB Control No. 2900-0108 in any correspondence. Do not send your completed VA Form 21P-4185 to this email address.
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.
INSTRUCTIONS: Please provide specific information about the gross income and expenses of your property and/or business, so we can determine eligibility for
benefits. Print all answers clearly. If an answer is "none" or "0," write that or line through the space provided. For additional space, attach a separate sheet, indicating
the item number to which the answers apply. Make sure to write the veteran's name and VA claim number on any attachments to the form.
Rental income: Net rental income is gross rental income less expenses. Depreciation and payments on the principal of a mortgage are not deductible. If the rental
property is partially occupied by the owner, report the gross income received and the proportionate part of the expenses. For example: If you own a two-family house
that is occupied by you and another family, report the gross income you receive from the other family and one-half of the expenses.
Business income: Net business income is gross income less operating expenses. Depreciation, withdrawals of cash or merchandise, and salaries paid you or your
partners are not deductible. Deductible operating expenses include cost of goods sold, rent, normal repairs, taxes (other than Federal income tax), salary or wages of
employees, insurance, interest on business debts, and similar expenses.
For more information on VA benefits, visit our web site at www.va.gov, contact us at https://iris.custhelp.com, or call us toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the number is 711. VA forms are available at www.va.gov/vaforms.
1. VETERAN'S NAME (First, Middle Initial, Last)
2. FIRST NAME-MIDDLE NAME-LAST NAME OF CLAIMANT (If other than veteran)
3. MAILING ADDRESS OF CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

5. TELEPHONE NUMBER (Include Area Code)

4. VA FILE NUMBER

6. WHAT PORTION OF RENTAL PROPERTY, IF ANY,
IS OCCUPIED BY CLAIMANT?

7. ADDRESS OF RENTAL PROPERTY

8. BRIEF DESCRIPTION OF RENTAL PROPERTY (Include number and type of
units)

9. ADDRESS OF BUSINESS

10. TYPE OR NATURE OF BUSINESS

STOCK INVENTORY
OF BUSINESS

LINE
NO.

1
2
3
4
5
6
VA FORM
XXX XXXX

11A. VALUE AT BEGINNING OF CURRENT CALENDAR
YEAR

$

(12A)
TOTAL EXPENSES RELATING TO RENTAL
PROPERTY OR OPERATION OF BUSINESS
NOTE: Do not list personal expenditures.
TAXES
UTILITIES (If furnished)

11B. VALUE AT END OF CURRENT CALENDAR YEAR

$
(12B)
EXPENSES FOR THE PERIOD
FROM (MM/DD/YY)

THRU (MM/DD/YY)

(If no dates are shown, report
expenses for last calendar year)

$

(12C)
EXPENSES FOR THE PERIOD
FROM (MM/DD/YY)

THRU (MM/DD/YY)

(If no dates are shown, report
expenses for current calendar year)

$

INSURANCE
INTEREST ON MORTGAGE
FUEL (If furnished)
NORMAL REPAIRS

21P-4185

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VETERAN'S SOCIAL SECURITY NO.

7
8

COST OF GOODS SOLD
RENT

9
10
11

EMPLOYEES' SALARIES
INTEREST ON BUSINESS DEBT
OTHER (Explain briefly in Item 13, "Remarks" )

12

TOTAL EXPENSES

$

$

IMPORTANT: Report total gross income in Line 1, total expenses in Line 2, and total net income in Line 3. If the property or business is owned
jointly, report your share of the net income in Line 4 and your fractional share of property ownership in Line 5. List the name(s), address(es), and
fractional share(s) of ownership for all remaining owner(s) in Line 6. If your spouse and/or dependent child(ren) are joint owners, report their net
property or business income in Item 14, " Remarks."

LINE
NO.

(13A)
GROSS INCOME, TOTAL EXPENSES, AND NET
INCOME FROM PROPERTY OR BUSINESS

(13B)
EXPENSES FOR THE PERIOD
FROM (MM/DD/YY)

THRU (MM/DD/YY)

(If no dates are shown, report expenses
for last calendar year)

(13C)
EXPENSES FOR THE PERIOD
FROM (MM/DD/YY)

(If no dates are shown, report expenses
for current calendar year)

1

GROSS INCOME FROM RENTAL PROPERTY AND
BUSINESS

2

TOTAL EXPENSES (Enter total from line 12, above)

3

NET INCOME FROM RENTAL PROPERTY OR
RECEIPTS FROM BUSINESS (Subtract line 2 from line 1)

4

CLAIMANT'S SHARE OF NET INCOME FROM RENTAL
PROPERTY OR RECEIPTS FROM BUSINESS

$

$

5

SHARE OF PROPERTY OR BUSINESS OWNED BY
CLAIMANT (Fractional)

$

$

$
$

THRU (MM/DD/YY)

$
$

$
NOTE: Complete Items 4, 5, and 6 only if property or business is owned jointly.

$

LIST THE NAME(S), ADDRESS(ES), AND FRACTIONAL SHARES(S) OF OWNERSHIP FOR ALL REMAINING OWNERS
6

14. REMARKS

I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge.
15A. SIGNATURE OF CLAIMANT (Sign in ink)
16A. DAYTIME TELEPHONE NUMBER (Including Area Code)

15B. DATE (MM/DD/YYYY)
16B. EVENING TELEPHONE NUMBER (Including Area Code)

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK: Signature made by mark must be witnessed by two persons who know
the claimant personally, and the signatures and addresses of such witnesses must be shown below.
17A. SIGNATURE OF WITNESS (Sign in ink)

17B. PRINTED NAME AND ADDRESS OF WITNESS

18A. SIGNATURE OF WITNESS (Sign in ink)

18B. PRINTED NAME AND ADDRESS OF WITNESS

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material
fact knowing it to be false.
VA FORM 21P-4185, XXX XXXX

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