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

OMB Approved No. 2900-0101
Respondent Burden: 30 minutes
Expiration Date: XX/XX/20XX

OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
(VETERAN)
VA FILE NUMBER

FIRST, MIDDLE, LAST NAME OF VETERAN
YOUR COMPLETE MAILING ADDRESS

2V

VA REGIONAL OFFICE RETURN 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.
IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21P-0510) before completing this form. This form is used by veterans 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 7G, Net Worth, and Item 8, Family Medical Expenses. If you
receive Section 306 Pension, complete all items.
1A. YOUR SOCIAL SECURITY NUMBER

1B. YOUR SPOUSES'S SOCIAL SECURITY NUMBER

1C. FIRST, MIDDLE, LAST NAME OF YOUR SPOUSE

1D. YOUR SPOUSE'S DATE OF BIRTH (MM/DD/YYYY)

2. MARITAL STATUS (Check one box)
(1) MARRIED-LIVING WITH SPOUSE (You are legally married and live with your spouse or you live apart only for medical reasons.)
(2) MARRIED-NOT LIVING WITH SPOUSE (You are legally married but estranged from your spouse.)
Show the amount you contributed to your spouse's support during the last 12 months (in dollars)
If you separated within the last 12 months, show the date of separation (MM/DD/YYYY)
(3) NOT MARRIED (You have never married or are now divorced or widowed.)
If your marriage ended within the last 12 months, show the date of divorce or death (MM/DD/YYYY)
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 (in dollars)

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 THE NURSING HOME (Please include ZIP Code)

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?
YES
NO

5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
YES

(If you checked "YES," write in the VA File number of the other benefit)

NO

VA FORM
XXX XXXX

21P-0512V-1

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

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REPORT OF INCOME AND NET WORTH
7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)

NOTE: If no income or net worth was received from a particular source, write "0"or "none." DO NOT LEAVE ANY ITEMS BLANK. Exception: Report your
spouse's income only if you receive Section 306 Pension.
GROSS MONTHLY AMOUNTS (in dollars)
VETERAN
SPOUSE - SECTION 306 ONLY

SOURCE
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)

7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)

NOTE: If no income or net worth was received from a particular source, write "0"or "none." DO NOT LEAVE ANY ITEMS BLANK. Exception: Report your
spouse's income only if you receive Section 306 Pension.
SOURCE

LAST YEAR (in dollars)
VETERAN

SPOUSE - Sec. 306 Only

THIS YEAR (in dollars)
VETERAN

SPOUSE - Sec. 306 Only

GROSS WAGES FROM ALL
EMPLOYMENT
TOTAL INTEREST AND DIVIDENDS
ALL OTHER (Show Source)
ALL OTHER (Show Source)
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE LAST 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 of if you received any NEW source of income or any ONETIME income)
YES (If "YES," complete Items 7D, through 7F.)
NO (If "NO," go to Item 7G.)
7D. WHAT INCOME CHANGED?

7E. WHEN DID THE INCOME CHANGE?

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

(Show the dates you received any new income
or the date income changed (MM/DD/YYYY))

7F. HOW DID INCOME CHANGE?

(Explain what happened; for example, quit work,
got raise, received inheritance)

7G. VETERAN'S NET WORTH (Read Paragraph 5 of the EVR Instructions)

NOTE: Complete only if you receive Section 306 Pension. Skip to Item 9A if you receive Old Law Pension.
VETERAN (in dollars)

SOURCE

SURVIVING SPOUSE (in dollars)

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

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 9 of the EVR Instructions before signing)

10. TELEPHONE NUMBER (Include Area Code)

DAYTIME

9B. DATE (MM/DD/YYYY)

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-0512V-1, XXX XXXX

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