21-509 Statement of Dependency of Parent(s)

INSTRUCTIONS
FOR STATEMENT OF DEPENDENCY OF PARENTS
VA FORM 21-509
NOTE: Read very carefully, detach, and keep these instructions for your reference. Print all answers clearly. If an answer is
"none" or "0," write that. Your answer to every question is important to help us complete your claim. If you do not know the
answer, write "unknown." If additional space is necessary, please attach a separate sheet with your answer, and indicate the
item to which the answer implies.
A. How can I contact VA if I have questions?
If you have questions about this form, how to fill it out, or about benefits, contact your nearest VA regional office. You can locate the
address of the nearest regional office in your telephone book blue pages under "United States Government, Veterans" or call
1-800-827-1000 (Hearing Impaired TDD line 711). You may also contact VA by Internet at http://www.vba.va.gov/benefits/address.htm.
B. What do I use VA Form 21-509 for?
Use VA Form 21-509 if:
1. You are a veteran whose parents are dependent on you for support, and you are:
• Receiving compensation benefits based on a 30 percent or higher service-connected disability, or
• Receiving VA educational benefits based on enrollment of 1/2 time or more.
OR
2. You are the parent of a deceased veteran who:
• Died on active duty or as a result of service-connected injuries or disease prior to January 1, 1957, or
• Died on or after May 1, 1957, and before January 1, 1972, while a waiver of premiums of his/her U.S. Government Life
Insurance was in effect.
C. What is meant by "Parent" on this form?
The term "Parent" includes a natural parent, a parent through adoption, and a foster parent (including stepparents who stood in the
relationship of parent to the veteran).
SPECIFIC INSTRUCTIONS
Net Worth of Parent(s) (Items 5A, 5B, and 5C)
Report the current value of all the interest and rights you (the parent(s)) have in any kind of property. This includes real estate, stocks,
bonds and the amount of bank deposits, savings and loan accounts, and cash on hand. However, net worth does not include your (the
parent(s)) single family dwelling unit, reasonable lot area, and personal things you use every day like your vehicle, clothing, and
furniture. If property is owned jointly by yourself and your spouse, report one-half of the total value held jointly for each of you.
Income of Parent(s) (Items 6A, 6B, and 6C)
Report all income received for the 12 month period and for the calendar month immediately preceding the date of completing this
form, and the sources of income.
The term "income" means payments and benefits received from sources such as:
• Wages or salary (before any deductions) earned by all members of the parent(s)' household, including minors
• Actual contributions to the family by adult members outside of the household
• Social Security benefits, retirement pay, allotments, and family allowances
• Pension, compensation or insurance benefits (other than those received from the Department of Veterans Affairs)
• Interest and dividends
• Rents, property, business, and farm operations
When reporting net income for a business, farm, etc. attach a separate sheet showing gross income and itemized expenses. Net income
is gross income less the expenses of operating a rental property or a business or farm. Gross income includes both receipts in cash and
the market value of goods or services received in lieu of cash. Expenses include cost of goods sold (for businesses), normal repairs,
taxes, salary or wages of employees, insurance, interest on business debts (but not payment of principal), supplies purchased, and
other similar expenses.
VA FORM
XXX XXXX

21-509

SUPERSEDES VA FORM 21P-509, APR 2021,
WHICH WILL NOT BE USED.

Page 1

Expenses of Parent(s) (Items 7A, 7B, and 7C)
Report the expenses for the 12 month period and for the calendar month immediately preceding the date of completing this form.
Include expenses for rent (or housing), home repairs, maintenance, clothing, medical care, utilities, groceries, taxes, etc.
Dependents (Items 9A, 9B, 10A, 10B, 10C, and 10D)
Item 9A is to be completed by the parent(s) of a deceased veteran. Item 9B is to be completed by the veteran. Items 10A, 10B, 10C,
and 10D are to be completed whenever the parent(s) have dependents residing with the parent(s).
NOTE: Parent(s) must sign and date the form (Items 11A, 11B, 12A, and 12B). A veteran claiming his/her parent(s)

as dependent(s) must also date and sign the form (Items 13A and 13B).

IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the
place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your
claim (or a later date when you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognizes
marriages is available at http://www.va.gov/opa/marriage/.
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, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your
response is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to
provide their SSN under Title 38 USC 5101 (c) (1). 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 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.
Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). 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 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: 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 2900-0089, 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. 2900-0089 in any correspondence. Do not send your
completed VA Form 21-509 to this email address.

VA FORM 21-509, XXX XXXX

Page 2

OMB Approved No. 2900-0089
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX

STATEMENT OF DEPENDENCY OF PARENT(S)
IMPORTANT - Please read the attached instructions before completing this form.
1. NAME OF VETERAN (First Name, Middle Name, Last Name)

2. VA FILE NUMBER

3A. FULL NAME OF VETERAN'S PARENT
3B. DATE OF BIRTH (MM/DD/YYYY)

4A. FULL NAME OF VETERAN'S PARENT
3C. SOCIAL SECURITY NUMBER

3D. DATE PARENT BECAME FINANCIALLY DEPENDENT ON THE VETERAN

(MM/DD/YYYY)

4B. DATE OF BIRTH (MM/DD/YYYY)

4C. SOCIAL SECURITY NUMBER

4D. DATE PARENT BECAME FINANCIALLY DEPENDENT ON THE VETERAN

(MM/DD/YYYY)

5. NET WORTH
OWNER

A. DESCRTIPTION OF PROPERTY

(Include location of real property)

B. PRESENT MARKET VALUE

(Dollar Amount)

C. ENCUMBRANCE ON
PROPERTY

(Dollar Amount)

PARENT

PARENT

PRESENT SPOUSE
OF PARENT

6. INCOME
MEMBER OF
FAMILY

A. SOURCE FROM WHICH INCOME IS RECEIVED

B. INCOME FOR LATEST
CALENDAR MONTH FROM
EACH SOURCE

(Dollar Amount)

C. TOTAL FOR 12 MONTHS

(Dollar Amount)

VETERAN'S
PARENT

VETERAN'S
PARENT

PRESENT SPOUSE
OF PARENT

7. EXPENSES OF PARENT(S) (Including spouse if remarried)
INSTRUCTIONS: Enter below the expenses for you (the parent(s), including if remarried) for the 12 month period and for the calendar month immediately
preceding the date of completing this form, and the purposes for which paid out. Include expenses for rent (or housing), home repairs, maintenance, clothing,
medical care, utilities, groceries, taxes, etc.
A. TYPE OF EXPENSE (List separately)

VA FORM
XXX XXXX

21P-509

B. EXPENSES FOR LAST
CALENDAR MONTH

SUPERSEDES VA FORM 21P-509, APR 2021,
WHICH WILL NOT BE USED.

(Dollar Amount)

C. TOTAL FOR 12 MONTHS

(Dollar Amount)

Page 3

8. IF EXPENSES EXCEED INCOME, STATE FROM WHAT SOURCE SUCH EXPENSES ARE MET

9A. PARENTS ONLY - ARE THERE ANY PERSONS LIVING IN YOUR HOUSEHOLD DEPENDENT SOLELY UPON YOU FOR SUPPORT?
YES (If "YES," complete Items 10A, 10B, 10C, and 10D)

NO

9B. VETERANS ONLY - ARE THERE ANY PERSONS LIVING IN YOUR PARENT(S)' HOUSEHOLD DEPENDENT SOLELY UPON YOU FOR SUPPORT?
YES (If "YES," complete Items 10A, 10B, 10C, and 10D)

NO

10. INFORMATION RELATING TO PERSONS SOLELY DEPENDENT UPON PARENT(S) (If additional space is needed use separate sheet)
A. NAME OF DEPENDENT PERSONS

B. DATE OF BIRTH

(MM/DD/YYYY)

C. RELATIONSHIP TO
PARENT(S)

D. REASON FOR DEPENDENCY

I CERTIFY THAT the preceding statements are true and correct to the best of my knowledge and belief.
11A. DATE (MM/DD/YYYY)

11B. SIGNATURE OF PARENT (Sign in ink)

11C. ADDRESS OF MOTHER

11D. DAYTIME PHONE NUMBER

12A. DATE (MM/DD/YYYY)

12B. SIGNATURE OF PARENT (Sign in ink)

12C. ADDRESS OF FATHER

12D. DAYTIME PHONE NUMBER

13A. DATE (MM/DD/YYYY)

13B. SIGNATURE OF VETERAN (Sign in ink)

13C. ADDRESS OF VETERAN

13D. DAYTIME PHONE NUMBER

11E. EVENING PHONE NUMBER

12E. EVENING PHONE NUMBER

13E. EVENING PHONE NUMBER

WITNESSES - If you sign by (X), your mark must be witnessed by two persons who know you personally and the signature and address of the witnesses must be
shown.
14A. SIGNATURE OF WITNESS (Sign in ink)

14B. ADDRESS OF WITNESS

15A. SIGNATURE OF WITNESS (Sign in ink)

15B. ADDRESS OF WITNESS

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-509, XXX XXXX

Page 4