21P-0510 Eligibility Verification Reports Instructions

OMB Control No. 2900-0101
Respondent Burden: 30 minutes
Expiration Date: XXXXXXX

ELIGIBILITY VERIFICATION REPORT INSTRUCTIONS
NOTE: Read very carefully and keep these instruction sheets for your reference.
The Eligibility Verification Report (EVR) form will refer you to the instruction paragraphs that apply to you. There are specific instructions for each type of
EVR. You can determine what type of EVR you have by looking at the number in the upper right hand
corner on the front of this form. This number is next to the form title "Eligibility Verification Report."

General Information
A. How can I contact VA if I have questions?
If you have questions about this form, how to fill it out, or about benefits,
contact VA at 1-800-827-1000 (for the Hearing Impaired TDD line 711).
You may also contact VA by Internet at: https://iris.custhelp.va.gov/. The
mailing address of the nearest VA regional office can be found in your
telephone book blue pages under "United States Government," or at
www.va.gov/directory.
B. How do I complete my EVR?
Print all answers clearly. If you must write an answer do so very clearly
and plainly. If an answer is "none" or "0," write that or line through the
space provided. Answer all questions unless the instructions specifically
indicate that the item does not have to be answered. For additional space,
attach a separate sheet, indicating the item number to which the answers
apply. Make sure to write the veteran's name and VA claim number on
any attachments to the EVR.
C. What do I do when I have completed my EVR?
Make sure you sign and date the EVR. When you have completed the
EVR, mail it or take it to the VA address shown on the front of the EVR.
If no address is shown, mail or take the EVR to the nearest VA regional
office. Be sure to attach any materials that support and explain your claim.
Also, make a photocopy of your EVR and everything that you submit to
VA before you mail it.
D. What are aid and attendance and housebound benefits?
VA may pay a higher rate of benefits to a veteran, surviving spouse, or
surviving parent who is blind, a patient in a nursing home, or otherwise
needs regular aid and attendance. VA may also pay a higher rate of
pension to a veteran who is permanently confined to his or her home
because of a disability. A surviving spouse must be receiving or entitled to
receive Improved Pension to qualify for a higher rate of pension based on
being permanently confined to his or her home because of a disability.
You are receiving Improved Pension if entitlement to pension was
established on or after January 1, 1979. If you wish to claim any of these
benefits and are not in a nursing home, attach a separate sheet of paper
stating the benefits you are claiming. Also, submit a statement from your
doctor showing the extent of your disabilities. If you are in a nursing
home, be sure to complete the items on the EVR pertaining to nursing
home care and provide the complete address and phone number of the
nursing home.

VA FORM
XXXX

21P-0510

E. How does receiving Medicaid-covered nursing home care affect my
pension?
Pension payments may be reduced to $90 per month if you have no
dependents and are receiving nursing home care which is covered by
Medicaid. This reduction only applies if you are receiving Improved
Pension. The reduction does not apply if you receive Parents' Dependency
and Indemnity Compensation (DIC), Old Law Pension, or Section 306
Pension. You are receiving Old Law Pension, or Section 306 Pension if
entitlement to pension was established before January 1, 1979.
F. What if my income or dependency information changes after I
return the EVR?
If there is a significant increase in your family income or net worth, or if
there is any change in your marital status or the status of your dependents
after you return your EVR, notify VA immediately. Fully describe the
change and furnish your name, VA claim number, and Social Security
number. Do not wait to report the change on next year's EVR. If you do
not promptly notify us of these changes, this may result in an overpayment
in your account.
G. What if I believe that VA has made an error in processing or
deciding my benefits ?
You have a right at any time to submit additional information or to have a
personal hearing to explain or clarify your statements. You also have the
right to be represented at a hearing by the representative of your choice.
For more information about personal hearings or assigning a
representative, contact VA as shown in Item A.
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 powerof-attorney and the fee agreement requirements.

SUPERSEDES VA FORM 21P-0510, JUL 2021,
WHICH WILL NOT BE USED.

Page 1

INSTRUCTION PARAGRAPHS
1. NUMBER OF UNMARRIED, DEPENDENT CHILDREN
VA recognizes the veteran's biological children, adopted children, and stepchildren as dependents. But these children must be unmarried and:
• under age 18, or
• between 18 and 23 and pursuing an approved course of education, or
• of any age if they became permanently unable to support themselves before reaching age 18.
Report a child living in your household as "in your custody." Report a child who is not living with you as "not in your custody."
If a child between the ages of 18 and 23 who is receiving benefits or has been established as your dependent based on school attendance has stopped
attending school, show this change on the EVR. If a child (regardless of age or status) has married, this must be shown on the EVR also. If a change in a
child's school or marital status occurs after you complete the EVR, notify VA immediately.
2. INCOME
You are required to report all income unless the instructions in this paragraph specifically indicate that the item does not apply to you. If you are not sure
about a particular type of income, report it and provide a full explanation of the source of the income. If any income does not count, VA will exclude it
when computing your income for VA purposes. If you do not receive income from a particular source, write "0" or "none" in the space provided. Do not
leave the space blank.
Report the gross amounts before you take out deductions for taxes, insurance, etc.
EXAMPLE: Your monthly Civil Service check is $365.60. The deduction for taxes is $15. The deduction for health insurance is $19.40.

$365.60 Check Amount
15.00 Deduction for Taxes
+19.40 Deduction for Insurance
Amount to report on EVR $400.00
Do report:

Do NOT report:

VA pension that you receive under another claim number. Report as
"other" monthly income.

VA pension that you receive under this claim number.

VA compensation that you receive under this or another claim number.
Report as "other" monthly income.

Any income you or your dependents received before the effective date of
your award of benefits, if the effective date is during the first year shown
on your EVR form.

Type 2S, 2V, 3 EVRs only: If you receive Old Law Pension (fixed rate of
pension since 1960), report Supplemental Security Income (SSI) benefits.

SSI benefits unless you receive Old Law Pension (fixed rate of pension
since 1960).

Type 6, 7, 8, 9C, 9S EVRs only: VA insurance benefits. Report as "other"
annual income.
Type 6, 7, 8, 9C, 9S EVRs only: all income received by each child. If each
of your children has exactly the same income and your EVR has a space
for reporting a child's income, you may write "all" at the top of the child
income column on the EVR.
VA education benefits. Report as "other" annual income.
If you are not sure whether to report income as "monthly income" or "annual income," don't worry. You may report it in either category. The important
thing is to report all income, clearly state its source, and not to report the same income twice on the EVR.
Report under "monthly income:"

Report under "annual income:"

Gross monthly amount of income you receive such as government,
retirement or annuity checks.

Gross annual wages from employment.
Annual interest and dividends. This includes but is not limited to interest
on savings accounts, checking accounts, certificates of deposit, mutual
funds, and VA insurance.
All other income that is not shown in another section (for example, VA
education benefits, rental income, insurance, net income from the
operation of a business, unemployment compensation, IRA distributions,
gifts, inheritances, gambling winnings, etc.)

VA Form 21P-0510, XXXX

Page 2

INSTRUCTION PARAGRAPHS (Continued)
3. MONTHLY INCOME
Social Security benefits: VA receives information from the Social Security Administration (SSA) about the rates paid to most individuals who receive
benefits from both VA and SSA. If an amount is preprinted in the Social Security block on your EVR, it came from Social Security records or is based on
information you have furnished in the past. The amount shown is the sum of your monthly amount and your Medicare premium (if any). See the
EXAMPLE under Item 2. If the preprinted amount is correct or is within $1 of the correct rate, do not make any entry. If the preprinted amount is wrong by
more than $1, cross it out, enter the correct amount, and, if possible, attach to your EVR an award letter or other notice from SSA showing your correct rate.
If any Social Security block does not contain a preprinted amount, enter the applicable Social Security rate or "0," as appropriate.
Military retirement: Military retirement means a monthly check from the Army, Navy, Air Force, Coast Guard or Marine Corps and is usually based on
20 or 30 years service. Do not report your VA benefits as military retirement. Report VA benefits as "other income."
4. ANNUAL INCOME
Last year column: The income reported for the past year should be the actual amounts of gross income received. Use your W-2 forms, bank statements,
etc. Do not rely on your memory, and do not estimate the amount of income already received.
Next year column: The income you report for the coming year should be your best estimate at this time. If there is a significant increase in your income
after you complete this EVR, notify VA immediately. DO NOT wait until VA sends you another EVR next year.
5. NET WORTH
Net worth is the market value of all interest and rights you have in any kind of property less any mortgages or other claims against the property. However,
net worth does not include the house you live in or a reasonable area of land it sits on. Net worth also does not include the value of personal things you use
everyday like your vehicle, clothing, and furniture. If property is owned jointly by yourself and your spouse, report one-half of the total value held jointly
for each of you.
Type 2S, 2V, 3 EVRs: Report your net worth only if you receive Section 306 Pension (fixed rate of pension since 1978). Do not report the net worth of
your spouse.
Type 6, 7, 8, 9S EVRs: You must report net worth for yourself and all dependents for whom you are receiving benefits.
Type 9C EVR: If you are a child claiming or receiving pension in your own right, report your net worth. If you are claiming or receiving pension as the
custodian of a child or children, report the child's net worth and your net worth unless you are an institutional custodian. If you are also the child's parent,
you are married, and you live with your spouse, report your and your spouse's net worth.
6. FAMILY MEDICAL EXPENSES
Note: Do not report medical expenses if your only income is VA pension or SSI. If VA pension or SSI is your only income, please skip to paragraph 7
of the instructions.
Family medical expenses actually paid by you may be deductible from your income. Report the amount of unreimbursed medical expenses, including the
Medicare deduction, you paid for yourself or relatives who are members of your household. Any expenses reasonably related to medical or dental care of
yourself or dependents (including health insurance premiums) may be allowed as medical expenses. If you are not sure whether a particular expense can be
allowed, furnish a complete description of the purpose of the payment. We will let you know if an expense cannot be allowed.
Do not include any expenses for which you were or will be reimbursed. Do not report any medical expenses paid before the effective date of your benefits.
Type 2S, 2V, 3
EVR:

Do not report medical expenses unless you receive Section 306 Pension and have been notified by VA that your pension will be
terminated due to excessive income. Note: Allowable medical expenses may be used to reduce your countable income; however,
these expenses cannot be used to increase the protected rate of pension that you receive.

Type 4 EVR:

If you have income other than VA benefits or SSI, you should report medical expenses. Generally your rate will not be increased
unless the medical expenses you paid (including Medicare premiums) exceed 5 percent of your countable annual income. Note: If
your spouse is the veteran's other parent and you live together, your spouse will receive a separate EVR and VA Form 21P-8416.
You may report all your and your spouse's medical expenses on a single VA Form 21P-8416 or each parent may report his or her
medical expenses on separate VA Forms 21P-8416. If you paid medical expenses from a joint account, one parent can claim all
the expenses or you may divide up the expenses. Do not report the same medical expenses.

Type 6, 7, 8, 9C,
9S EVR:

If you have income other than VA benefits or SSI, you should report medical expenses. Generally your rate of pension will not be
increased unless the medical expenses you paid (including Medicare premiums) exceed 5 percent of the Maximum Annual
Pension Rate (MAPR). Rates are frequently changed, so it is not possible to keep this information current in these instructions.
You can find out what the current MAPR is by contacting your nearest VA regional office at 1-877-294-6380 (Hearing
Impaired TDD line 1-800-829-4833).

VA Form 21P-0510, XXXX

Page 3

INSTRUCTION PARAGRAPHS (Continued)
6. FAMILY MEDICAL EXPENSES (Continued)
If the amount of medical expenses is not preprinted on your EVR, you must itemize any medical expenses you wish to claim. Report unreimbursed medical
expenses on VA Form 21P-8416, "Medical Expense Report." If you need a copy of this form, contact the VA at 1-877-294-6380 (Hearing Impaired TDD
line 711). You may also download the form at www.va.gov/vaforms. Note: If your current rate of benefits is based on allowance of a continuing deduction
for nursing home fees or other recurring medical expenses, you must complete VA Form 21P-8416 to confirm that you actually paid these expenses or your
award will be adjusted retroactively to remove the deduction. This will result in an overpayment in your account and possible termination of benefits.
If the amount of medical expenses is preprinted on your EVR, write in the total amount of unreimbursed medical expenses you actually paid and the amount
you expect to pay during the next income reporting year. If the amounts you enter are substantially the same as the amount preprinted on the EVR, you may
submit the EVR without itemizing your medical expenses on VA Form 21P-8416.
IMPORTANT
You may be asked to verify the amounts you actually paid, so keep all receipts or other documentation of payments for at least 3 years after we make a
decision on your medical expense claim. If you are unable to provide documentation of the claimed medical expenses when asked to do so by VA, your
benefits will be retroactively reduced or terminated.
7. EDUCATIONAL OR VOCATIONAL REHABILITATION EXPENSES
Type 6, 7, 8, 9C, 9S EVRs: Educational or vocational rehabilitation expenses actually paid by you may be deductible from your income. Educational or
vocational rehabilitation expenses are amounts paid for courses of education or vocational rehabilitation that you are pursuing, including tuition, fees, and
materials. Report only your educational expenses. Do not include any expenses for which you were or will be reimbursed. Do not report your dependents'
expenses.
Note: Do not report educational or vocational rehabilitation expenses if you are using the EVR to supplement a pending claim. If entitlement is established,
you will have an opportunity to report your expenses at the end of the year.
8. FAMILY MAINTENANCE (Hardship) EXPENSES
Report hardship expenses on the EVR only if VA is currently excluding your children's income on the grounds of hardship. If this applies to you, show the
total expenses for family maintenance expected for the next 12 months.
VA can exclude all or part of a dependent child's income if it is not reasonably available to you or if it would cause hardship to consider this income in
determining your rate of pension. If VA is not currently excluding your children's income and you feel that it should be, you will need to complete VA
Form 21-0571, "Application for Exclusion of Children's Income." Contact VA at the address shown at the top of the EVR form and we will send you this
form. You may also download this form at www.va.gov/vaforms/.
9. SIGNATURE
The EVR form must be signed by the payee who is recognized by VA. Normally, this will be the person to whom the monthly check is payable. The EVR
cannot be signed by another person on behalf of the beneficiary unless that person has been recognized as the payee by VA. If you are capable of handling
your VA funds but are unable to sign your name, you may sign by "X" mark or thumb print. If you sign by "X" mark or thumb print, furnish the following
statement on a separate sheet which should be attached to the EVR: "I hereby certify that the information on this form is true and correct to the best of my
knowledge and belief." Place your mark or thumb print under this statement and have it signed by two witnesses who must also print their names and
addresses. Be sure to write the veteran's name and VA claim number on the attachment.
PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the
Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications,
epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the
administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system
of records, 58VA21/22/28, Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register.
Your to response is required to obtain or retain benefits. Giving us your and your dependents SSN account information is mandatory. Applicants are
required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 USC 5101 (c) (1). The VA will not deny an
individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1,
1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you
submit are considered confidential (38 USC 5701). Information submitted is subject to verification through computer matching programs with other
agencies.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this project is 2900-0101, and it expires XX/XX/20XX. Public reporting
burden for this collection of information is estimated to average 30 minutes per respondent, per year, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports
Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0101 in any correspondence. Do not send your completed
VA Form 21P-0510 to this email address.
VA Form 21P-0510, XXXX

Page 4