21P-0512s-1 Old Law and Section 306 Eligibility Verification Report

OMB Approved No. 2900-0101
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/20XX
FIRST, MIDDLE, LAST NAME OF VETERAN

FIRST, MIDDLE, LAST NAME OF SURVIVING SPOUSE

OLD LAW AND SECTION 306 ELIGIBLITY
VERIFICATION REPORT
(SURVIVING SPOUSE)

VA FILE NUMBER

2S

VA REGIONAL OFFICE RETURN ADDRESS

COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE

(IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21P-0510) before completing this form. This form is used by surviving spouses receiving Old
Law or Section 306 Pension. If you have been receiving a fixed rate of pension since 1960, you receive Old Law Pension. If you have been receiving a fixed rate of
pension since 1978, you receive Section 306 pension. If you receive Old Law Pension, do not complete Item 2G, New Worth, and Item 3, Family Medical Expenses. If
you receive Section 306 Pension, complete all items).
1A. VETERAN'S SOCIAL SECURITY NUMBER

1B. YOUR SOCIAL SECURITY NUMBER

1C. YOUR DATE OF BIRTH (MM/DD/YYYY)

2. MARITAL STATUS (Check one box)
(1) I HAVE NOT REMARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran's death)

(Date) (MM/DD/YYYY) AND I AM STILL MARRIED (You married after the veteran's death and you are currently

(2) I REMARRIED ON

married. Enter the date you married your current spouse.)
(Date) (MM/DD/YYYY) (You remarried

(3) I REMARRIED AFTER VETERAN DIED BUT MARRIAGE ENDED BY DEATH OR DIVORCE ON

but you are not currently married.) Show the date your latest marriage ended.)
3A. NUMBER OF UNMARRIED DEPENDENT CHILDREN (See Paragraph 1 of the

EVR Instructions)

IN YOUR CUSTODY

3B. AMOUNT CONTRIBUTED DURING PAST 12 MONTHS TO CHILDREN NOT IN
YOUR CUSTODY

NOT IN YOUR CUSTODY

4A. ARE YOU A PATIENT IN A NURSING HOME? (If "YES," Complete Items 4B

4B. SHOW THE DATE YOU ENTERED THE NURSING HOME (MM/DD/YYYY)

thru 4D) If "NO," go to Item 5.)
YES

NO

4C. ENTER THE NAME, COMPLETE ADDRESS, AND TELEPHONE NUMBER OF
NURSING HOME (Please include ZIP Code)

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?

5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME
DURING THE LAST 12 MONTHS?

6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR
SURVIVING SPOUSE?

YES

YES

YES

NO

NO

NO

(If you check "YES," write in the VA File Number of the other benefit):

REPORT OF INCOME AND NET WORTH

NOTE: If you have no income or net worth from a particular source, write "0"or "none". DO NOT LEAVE ANY ITEMS BLANK.
7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
SOURCE

GROSS MONTHLY AMOUNTS

SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY INCOME (SSI)/PUBLIC ASSISTANCE
OTHER MONTHLY INCOME (Show Source)

VA FORM
XXX XXXX

21P-0512S-1

SUPERSEDES VA FORM 21P-0512S-1, JUL 2021,
WHICH WILL NOT BE USED.

Page 1

7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
NOTE: If you have no income or net worth from a particular source, write "0"or "none". DO NOT LEAVE ANY ITEMS BLANK.
SOURCE

THIS YEAR

LAST YEAR

GROSS WAGES FROM ALL EMPLOYMENT
INTEREST AND DIVIDENDS
ALL OTHER (Show Source)
ALL OTHER (Show Source)
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE PAST 12 MONTHS? (Answer "NO" if there were no income changes or if the only change was a

Social Security/VA cost-of-living adjustment. Answer "YES" if there were any other income changes or if you received any NEW source of income or any ONETIME income)
YES

NO

(If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)

7D. WHAT INCOME CHANGED? (Show what

income changed; for example, wages, city
pension, etc.)

7E. WHEN DID THE INCOME CHANGE? (Show the dates

you received any new income or the date income
changed)

7F. HOW DID INCOME CHANGE? (Explain what happened;

for example, quit work, got raise, received inheritance)

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
NOTE: Complete only if you receive Section 306 Pension. Skip to Item 19A if you receive Old Law Pension.
SOURCE

SURVIVING SPOUSE

CASH/NON-INTEREST BEARING BANK
ACCOUNTS
INTEREST BEARING BANK ACCOUNTS
IRAs, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY
8. FAMILY MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)

NOTE: Skip to Item 9A if you receive Old Law Pension.
If Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21P-8416, Medical Expense Report, to report your medical
expenses.
9A. SIGNATURE OF CLAIMANT, CUSTODIAN OR GUARDIAN (Read paragraph 6 of the EVR Instructions before signing)

9B. DATE (MM/DD/YYYY)

10. TELEPHONE NUMBERS (Include Area Code)
DAYTIME

EVENING

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 is false, or fraudulent acceptance of any payment to which you are not entitled.

VA FORM 21P-0512S-1, XXX XXXX

Page 2