21P-0518-1 Improved Pension Eligibility Verification Report (Surviv

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

FIRST NAME - MIDDLE NAME - LAST NAME OF SURVIVING SPOUSE

COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE

(SURVIVING SPOUSE WITH NO CHILDREN) 8

VA FILE NUMBER

VA REGIONAL OFFICE RETURN ADDRESS

IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER

1B. VETERAN'S SOCIAL SECURITY NUMBER

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

2. YOUR MARITAL STATUS (Check only 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 married. Enter the date you married your current spouse.)

(2) I REMARRIED ON

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

(Date)

(MM/DD/YYYY). (You remarried but you are not currently married. Show the date your latest marriage ended.)
3. NUMBER OF UNMARRIED, DEPENDENT CHILDREN (See Paragraph 1 of the EVR Instructions)
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.)

$

4C. ENTER THE NAME, COMPLETE ADDRESS, AND
TELEPHONE NUMBER OF NURSING HOME

(Please include Zip Code)

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

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

NO

5. DID YOU RECEIVE ANY 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

VA FORM
XXX XXXX

NO

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

21P-0518-1

SUPERSEDES VA FORM 21P-0518-1, JUL 2021,
WHICH WILL NOT BE USED.

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

SURVIVING SPOUSE
$

SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
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.
FROM (MM/DD/YYYY):
FROM (MM/DD/YYYY):
SOURCE
THRU (MM/DD/YYYY):
THRU (MM/DD/YYYY):
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 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)
SOURCE
SURVIVING SPOUSE
$
CASH/NON- INTEREST-BEARING BANK ACCOUNTS
INTEREST-BEARING BANK ACCOUNTS
IRA'S, 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)

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. SURVIVING SPOUSE'S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR Instructions). Show
amounts paid by you during the past 12 months. DO NOT REPORT CHILDREN'S EXPENSES.
$
10A. SIGNATURE OF PAYEE (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-0518-1, XXX XXXX

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