21P-0516-1 Improved Pension Eligibility Verification Report (Vetera

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

FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(VETERAN WITH NO CHILDREN)
YOUR COMPLETE MAILING ADDRESS

6

VA FILE NUMBER
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) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER

1B. YOUR SPOUSE'S SOCIAL SECURITY NUMBER

1C. FIRST, MIDDLE, LAST NAME OF SPOUSE

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

2. MARITAL STATUS (Check only one box)
(1)

MARRIED-LIVING WITH SPOUSE (You are legally married and you live with your spouse or are separated 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 $
If you separated within the last 12 months, show the date of separation (MM/DD/YYYY)
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)

(3)

3. NUMBER OF UNMARRIED, DEPENDENT CHILDREN (See Paragraph 1 of the EVR Instructions, VA Form 21-0510)
IN YOUR CUSTODY

NOT IN YOUR CUSTODY

AMOUNT CONTRIBUTED DURING PAST 12 MONTHS TO CHILDREN NOT IN YOUR CUSTODY $
4A. ARE YOU A PATIENT IN A NURSING HOME?
YES
NO (If "Yes," Complete Items 4B thru 4D. If "No," go to Item 5.)
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME (MM/DD/YYYY)

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?
YES
NO
4E. SHOW THE DATE YOUR MEDICAID COVERAGE STARTED (MM/DD/YYYY)
5. DID EITHER YOU OR YOUR SPOUSE RECEIVE ANY WAGES OR WERE EITHER OF 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

VA FORM
XXX XXXX

NO

(If "Yes," write in the VA file number of the other benefit)

21P-0516-1

SUPERSEDES VA FORM 21P-0516-1, JUL 2021,
WHICH WILL NOT BE USED.

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7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
GROSS MONTHLY AMOUNTS (If no income was received from a particular source, write "0" or "none." VA WILL INTERPRET A BLANK SPACE AS "NONE" or "0.")

SOURCE
SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
MILITARY RETIREMENT

VETERAN
$

SPOUSE
$

OTHER (Show Source)
OTHER (Show Source)
7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
If no income was received from a particular source, write "0" or "none." VA WILL INTERPRET A BLANK SPACE AS "NONE" OR "0."

NOTE: Report annual income for the dates indicated. If no dates are shown above the columns that follow, then report last calendar year (January
through December) income in the left-hand column and current calendar year income in the right-hand column.
VETERAN

SPOUSE

DATES (MM/DD/YYYY) DATES (MM/DD/YYYY) DATES (MM/DD/YYYY) DATES (MM/DD/YYYY)
SOURCE
FROM:
FROM:
FROM:
FROM:
THRU:
THRU:
THRU:
THRU:
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 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 ONE-TIME 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)
VETERAN
$
CASH/NON- INTEREST-BEARING BANK ACCOUNTS
SOURCE

SPOUSE
$

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

Normally, medical expenses are reported at the end of the year. If you are using this form as your annual Eligibility Verification Report and
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. If you are using this form as a supplement to a pending claim, you do not need to report medical expenses. If entitlement is
established, you will have an opportunity to report your medical expenses at the end of the year.
9. VETERAN'S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR Instructions)

Show amounts paid by you during the last 12 months. DO NOT REPORT DEPENDENTS' EXPENSES.
10A. SIGNATURE OF VETERAN (Read paragraph 9 of the EVR Instructions before signing)

DAYTIME

$

10B. DATE SIGNED (MM/DD/YYYY)

10C. TELEPHONE NUMBERS (Include Area Code)
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-0516-1, XXX XXXX

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