21P-0519c-1 Improved Pension Eligibility Verification Report (Child

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

IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(CHILD OR CHILDREN)

FIRST, MIDDLE, LAST NAME OF VETERAN

VA FILE NUMBER

YOUR COMPLETE MAILING ADDRESS

VA REGIONAL OFFICE RETURN ADDRESS

9C

IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.

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.

1A. FULL NAME OF
EACH CHILD

(First, middle initial, last)

1B. DATE OF
BIRTH

(MM/DD/YYYY)

1C. SOCIAL
SECURITY
NUMBER

1D. MARITAL STATUS

1E. SCHOOL STATUS

MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED

STOPPED SCHOOL

NEVER MARRIED

DISABLED CHILD

MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED

STOPPED SCHOOL

NEVER MARRIED

DISABLED CHILD

MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED

STOPPED SCHOOL

NEVER MARRIED

DISABLED CHILD

MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED

STOPPED SCHOOL

NEVER MARRIED

DISABLED CHILD

MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED

STOPPED SCHOOL

NEVER MARRIED

DISABLED CHILD

MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED

STOPPED SCHOOL

NEVER MARRIED

DISABLED CHILD

MARRIED

ATTENDS SCHOOL

DIVORCED/WIDOWED

STOPPED SCHOOL

NEVER MARRIED

DISABLED CHILD

1F. ATTENDED SCHOOL
CONTINUOUSLY
SINCE AGE 18

YES

NO

DATE LEFT SCHOOL

(MM/DD/YYYY)
YES

NO

DATE LEFT SCHOOL

(MM/DD/YYYY)
YES

NO

DATE LEFT SCHOOL

(MM/DD/YYYY)
YES

NO

DATE LEFT SCHOOL

(MM/DD/YYYY)
YES

NO

DATE LEFT SCHOOL

(MM/DD/YYYY)
YES

NO

DATE LEFT SCHOOL

(MM/DD/YYYY)
YES

NO

DATE LEFT SCHOOL

(MM/DD/YYYY)

2. DID ANY CHILD ON THIS AWARD RECEIVE WAGES AT ANY TIME DURING THE LAST 12 MONTHS?
YES

NO

REPORT OF INCOME AND NET WORTH

IMPORTANT NOTE ABOUT ITEMS 3A THROUGH 3G:

Child Claimants or Payees: If you are a child claiming or receiving pension in your own right, report your income and net worth in the CHILD columns and leave
the CUSTODIAN column blank.

VA FORM
XXX XXXX

21P-0519C-1

SUPERSEDES VA FORM 21P-0519C-1, JUL 2021,
WHICH WILL NOT BE USED.

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REPORT OF INCOME AND NET WORTH (Continued)

IMPORTANT NOTE ABOUT ITEMS 3A THROUGH 3G:
Custodians of Children: If you are claiming or receiving pension as the custodian of a child or children, report the child's income and net worth in the CHILD
columns, and enter your income and net worth in the CUSTODIAN columns. If you are also the child's parent, you are married, and you live with your spouse, add
your and your spouse's incomes and net worth together and enter the totals in the CUSTODIAN columns in Items 3A, 3B, and 3G.
Institutional Custodians: If you are an institutional custodian of a child, report the child's income and net worth in the CHILD columns. Leave the CUSTODIAN
columns blank.
3A. MONTHLY INCOME (in dollars) (Read Paragraphs 2 and 3 of the EVR Instructions)

If no income was received from a particular source, write "0" or "none." Do not leave any items blank unless the instructions specifically indicate that the item does
not have to be answered. VA will interpret a blank space as "0" or "None."
GROSS MONTHLY AMOUNTS
SOURCE

CHILD:

CUSTODIAN:

CHILD:

SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
OTHER RETIREMENT
OTHER (Show Source)
OTHER (Show Source)
3B. ANNUAL INCOME (in dollars) (Read Paragraphs 2 and 4 of the EVR Instructions)

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.
CHILD:

CUSTODIAN:

CHILD:

FROM (MM/DD/YYYY):

FROM (MM/DD/YYYY):

FROM (MM/DD/YYYY):

FROM (MM/DD/YYYY):

FROM (MM/DD/YYYY):

FROM (MM/DD/YYYY):

TO (MM/DD/YYYY):

TO (MM/DD/YYYY):

TO (MM/DD/YYYY):

TO (MM/DD/YYYY):

TO (MM/DD/YYYY):

TO (MM/DD/YYYY):

SOURCE

GROSS WAGES FROM ALL
EMPLOYMENT
TOTAL INTEREST AND
DIVIDENDS
ALL OTHER (Show Source)
3C. 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 (If "YES," complete Items 3D through 3F.)

3D. WHAT INCOME CHANGED? (Show what income

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

NO (If "NO," go to Item 3G.)
3E. WHEN DID THE INCOME CHANGE?

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

3F. HOW DID INCOME CHANGE? (Tell what happened; for

example, quit work, got raise, received inheritance)

3G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
SOURCE

CHILD:

CUSTODIAN:

CHILD:

CASH/NON-INTERESTBEARING BANK ACCOUNTS
INTEREST-BEARING BANK
ACCOUNTS
IRA'S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL
FUNDS, ETC.
REAL PROPERTY (Not your

home)

ALL OTHER PROPERTY
4. CHILD'S 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.
5. CHILD'S EDUCATIONAL EXPENSES (in dollars) (Read Paragraph 7 of the EVR Instructions)
If a school child answered "YES" to Items 1F and 2, report any educational expenses the child paid out of his/her own funds during the past 12 months.
A. SCHOOL CHILD'S NAME

6A. SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing)

6C. TELEPHONE NUMBERS (Include Area Code)

DAYTIME:

B. AMOUNT PAID

6B. DATE SIGNED (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-0519C-1, XXX XXXX

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