21-0513-1 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

OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
(CHILDREN ONLY)
3

VETERAN'S SOCIAL SECURITY NUMBER

NAME OF CHILD'S CUSTODIAN

VA FILE NUMBER

COMPLETE MAILING ADDRESS OF CHILD OR CUSTODIAN

VA REGIONAL OFFICE RETURN ADDRESS

(IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21P-0510) before completing this form. This form is used by children and custodians of
children 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).
1. CHILD(REN)'S MARITAL AND SCHOOL STATUS
List the children's names, dates of birth, and Social Security numbers, and indicate marital and school status for all children being paid on this award. If the child does
not have a Social Security number, write "No SSN" in the space provided for the child's Social Security number. If other children are on separate VA awards, they will
receive their own EVRs. If additional space is needed, attach a separate sheet of paper.
NOTE: Complete Item 1E only if the child is 18 years of age or older. Complete Item 1F only if the child is between the ages of 18 and 23 and has not been rated
disabled by VA. The child is considered to have attended school continuously if the child attended every regular school term except summer school or holiday periods.
If Block (2), STOPPED SCHOOL, is checked in Item 1E or "NO" is checked in Item 1F, provide the date the child last attended school in Item 1F.

A. FULL NAME OF
CHILD (First, middle

D. MARITAL STATUS
B. DATE OF BIRTH

initial, last)

(MM/DD/YYYY)

C. SOCIAL
SECURITY NUMBER

(1)
MARRIED

(2)
DIVORCED/
WIDOWED

(3)
NEVER
MARRIED

E. SCHOOL STATUS
(1)
ATTENDS
SCHOOL

(2)
STOPPED
SCHOOL

(3)
DISABLED
CHILD

F. ATTENDED SCHOOL
CONTINUOUSLY SINCE AGE 18
(1)
YES

(2)
NO

DATE LEFT SCHOOL

(MM/DD/YYYY)

2. REPORT OF INCOME AND NET WORTH
NOTE: If no income was received from a particular source, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
SOURCE

CHILD'S NAME:

CHILD'S NAME:

CHILD'S NAME:

SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY
INCOME (SSI)
OTHER INCOME (Show source)
OTHER INCOME (Show source)

VA FORM
XXX XXXX

21P-0513-1

SUPERSEDES VA FORM 21P-0513-1, JUL 2021,
WHICH WILL NOT BE USED.

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

CHILD:
DATES (MM/DD/YYYY)

CHILD:
DATES (MM/DD/YYYY)

DATES (MM/DD/YYYY)

FROM:

FROM:

FROM:

FROM:

FROM:

FROM:

THRU:

THRU:

THRU:

THRU:

THRU:

THRU:

GROSS
SALARY OR
WAGES
TOTAL
INTEREST
AND
DIVIDENDS
ALL OTHER

(Show
Source)

ALL OTHER

(Show
Source)

2C. 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 2D through 2F. If "NO," go to Item 2G.)

2D. WHAT INCOME CHANGED? (Show what income

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

2E. WHEN DID INCOME CHANGE? (Show the dates you

2F. HOW DID INCOME CHANGE? (Explain what

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

received any new income or the date income changed)

2G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
NOTE: Complete only if you receive Section 306 Pension. Skip to Item 4A if you receive Old Law Pension.
SOURCE

CHILD:

CHILD:

CHILD:

CASH, NON-INTEREST-BEARING BANK
ACCOUNTS
INTEREST-BEARING BANK ACCOUNTS
STOCKS, BONDS, MUTUAL FUNDS, ETC.
CERTIFICATES OF DEPOSIT, IRAs, ETC.
REAL PROPERTY (Excluding child's home)
ALL OTHER PROPERTY

3. CHILD'S MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)
NOTE: Skip to Item 4A 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.
4A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

4B. DATE SIGNED (MM/DD/YYYY)

5. TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME

B. 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-0513-1, XXX XXXX

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