21P-0571 Application for Exclusion of Children's Income

OMB Control No. 2900-0510
Respondent Burden: 45 minutes
Expiration Date: XXXXXXXX

APPLICATION FOR EXCLUSION OF CHILDREN'S INCOME
IMPORTANT: VA can exclude all or some of your children's income in computing your rate of pension if counting the children's income would
cause hardship or if this income is unavailable to you. Please fully complete this form if you wish to claim the exclusion.
1. FIRST, MIDDLE, LAST NAME OF VETERAN

2. VA FILE NUMBER

3. NAME OF CLAIMANT (If other than veteran)

4. VETERAN'S SOCIAL SECURITY NUMBER

5. ADDRESS OF CLAIMANT (Number and street or rural route, City or P. O., State, and ZIP Code)

ITEMS

CHILD'S NAME

CHILD'S NAME

CHILD'S NAME

CHILD'S NAME

6. CHILD'S DATE OF BIRTH
7. CHILD'S SOCIAL SECURITY NUMBER
8. IS ALL OF THIS CHILD'S INCOME
REASONABLY AVAILABLE TO YOU?

(If "No," complete Items 9 thru 13)
(If "Yes," skip to Item 14)

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

9. DESCRIBE THE SPECIFIC INCOME WHICH
IS NOT AVAILABLE TO YOU

(For example, Social Security, wages, etc.)

10. NAME OF PAYEE OF THE INCOME
DESCRIBED IN ITEM 9?

(Whose name appears on the check?)

11. DOES THE PERSON NAMED IN ITEM 10
RESIDE IN YOUR HOUSEHOLD ALL YEAR?

(If "No," complete Item 12)
(If "Yes," skip to Item 13)

12. HOW MANY MONTHS DID THE PERSON
NAMED IN ITEM 10 RESIDE IN YOUR
HOUSEHOLD DURING THE 12 MONTHS
PRECEDING THE DATE YOU ARE SIGNING
THIS FORM?
13. USE THIS SPACE TO FURNISH ANY OTHER
INFORMATION AS TO WHY YOU FEEL THIS
CHILD'S INCOME IS NOT REASONABLY
AVAILABLE TO YOU (If you need more

space, use Item 17)

VA FORM
XXXX

21P-0571

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14. AVERAGE MONTHLY EXPENSES FOR YOUR HOUSEHOLD
IMPORTANT: Use the space below to report your average monthly household expenditures. The figures you report should reflect your expenses
for the 12 months preceding the date you sign this form. Do not report medical expenses on this form. Report medical expenses on your Eligibility
Verification Report (EVR). VA will mail you an Eligibility Verification Report annually. If more space is needed to show expenses, use Item 17,
Remarks.
ITEM
NO.

AVERAGE MONTHLY EXPENSE

AMOUNT

ITEM
NO.

AVERAGE MONTHLY EXPENSE

A

RENT OR MORTGAGE PAYMENTS

J

FURNITURE AND HOUSEHOLD GOODS

B

FOOD

K

INTEREST PAYMENTS

C

UTILITIES AND HEAT

D

TELEPHONE

L

E

OPERATION OF AUTOMOBILE

M

F

PUBLIC TRANSPORTATION

N

G

CLOTHING

O

H

TAXES

P

I

INSURANCE (Specify type. If more than

one, furnish amount paid for each)

15. DO YOU EXPECT THAT THE LEVEL OF HOUSEHOLD EXPENSES
SHOWN IN ITEM 14 WILL CHANGE SIGNIFICANTLY DURING THE
NEXT 12 MONTHS?
YES

NO

(If "Yes," explain fully in Item 17)

AMOUNT

OTHER LIVING EXPENSES (Specify)

Q
R
16. HAS THERE BEEN ANY CHANGE IN THE INCOME OF ANY
MEMBER OF YOUR HOUSEHOLD SINCE THE LAST TIME YOU
REPORTED YOUR INCOME TO VA? (Do not report Social Security

or VA cost-of-living adjustments)
YES
NO
(If "Yes," explain fully in Item 17)

17. REMARKS (If you need more space, attach a continuation sheet)

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
18A. SIGNATURE OF CLAIMANT (Sign in ink)

18B. DATE (MM/DD/YYYY)

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, or for the fraudulent acceptance of any payment to which you are not entitled.
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 VAaccredited 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 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, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in
the Federal Register. Your response is required in order to obtain or retain benefits. Giving us your and your dependents' SSN account information is mandatory. Applicants are required to
provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 USC 5101 (c) (1). The VA will not deny an individual benefits for refusing to provide his or her
SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. 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-XXXX, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average XX 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-XXXX in any correspondence. Do not send your completed VA Form XXX to this email address.

VA FORM 21P-0571, XXXX

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