Form 21-0788 Information Regarding Apportionment of Beneficiary's Awa

OMB Approved No. 2900-0666
Respondent Burden: 30 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

INFORMATION REGARDING APPORTIONMENT OF BENEFICIARY'S AWARD

(DO NOT WRITE IN THIS SPACE)

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. All or part of a
veteran's disability award may be apportioned (paid) to the veteran's spouse, child, or dependent parent. A surviving spouse's
award may also be apportioned for the veteran's child or children. If you are certifying that you are married for the purpose of
VA benefits, your marriage must be recognized by the place where you and/or your spouse resided at the time of marriage, or
where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for benefits)
(38 U.S.C. § 103(c)). For additional space, or to describe any financial hardship (not otherwise reflected on this form) you are
experiencing or will experience based on the outcome of this claim, use Part III - Remarks. For more information, contact us at
https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD),
the Federal relay number is 711. VA forms are available at www.va.gov/vaforms. After completing the form, mail to:
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444.
1. VETERAN'S NAME (First, Middle Initial, Last)

2. VA FILE NUMBER (If known)

3A. PERSON COMPLETING THIS FORM (First, Middle Initial, Last) (If other than veteran)

C/CSS3B. MAILING ADDRESS (Number and street or rural route, city or

P.O., State and ZIP Code)

3C. TELEPHONE NUMBER (Include Area Code)
Daytime

3D. E-MAIL ADDRESS (If applicable)

Evening

4A. WHO ARE YOU REQUESTING AN APPORTIONMENT FOR? (List first, middle initial, and last names)

4B. WHAT IS HIS/HER RELATIONSHIP TO THE
VETERAN?

5A. HOW MUCH IS THE VETERAN OR VETERAN'S SURVIVING SPOUSE CONTRIBUTING TO THE PERSON(S)
FOR WHOM AN APPORTIONMENT IS BEING CLAIMED?

5B. HOW OFTEN ARE THE CONTRIBUTIONS MADE?

$
6. IF THE SPOUSE IS CLAIMING AN APPORTIONMENT, IS HE/SHE LIVING WITH ANOTHER PERSON AND
HOLDING HIMSELF/HERSELF OUT OPENLY TO THE PUBLIC AS THE SPOUSE OF THE OTHER PERSON?
YES

NO

(If "Yes," provide an explanation in Part III - Remaks):

7. HAS THE VETERAN'S CHILD(REN) BEEN
LEGALLY ADOPTED BY ANOTHER PERSON?
YES

NO

PART I - INCOME AND NET WORTH
Report all income and net worth. Report the gross amounts before you take out deductions for taxes, insurance, etc. If you do not receive income or net worth from a particular source, write
"0" or "none" in the space provided. Do not leave the space blank. Note: If you are the veteran or surviving spouse, report only your income and net worth. If you are the claimant or are filing
on behalf of the claimant(s), report all income and net worth for all persons for whom an apportionment is being claimed. If you are claiming an apportionment as the custodian of the veteran's
child or children, report your income and net worth and the income and net worth of the child(ren).

MONTHLY INCOME
SOURCE
1A. GROSS WAGES FROM ALL
EMPLOYMENT

VETERAN OR
SURVIVING SPOUSE
$

CUSTODIAN
$

PERSON APPORTIONMENT
IS CLAIMED FOR
$

PERSON APPORTIONMENT
IS CLAIMED FOR
$

1B. SOCIAL SECURITY
1C. RETIREMENT OR ANNUITIES
1D. SUPPLEMENTAL SECURITY
INCOME (SSI) / PUBLIC ASSISTANCE
1E. OTHER INCOME (Show source)
1F. OTHER INCOME (Show source)
NET WORTH
SOURCE
2A. CASH/NON-INTEREST-BEARING
BANK ACCOUNTS

VETERAN OR
SURVIVING SPOUSE
$

CUSTODIAN
$

PERSON APPORTIONMENT
IS CLAIMED FOR
$

PERSON APPORTIONMENT
IS CLAIMED FOR
$

2B. INTEREST-BEARING BANK
ACCOUNTS
2C. IRAS, KEOGH PLANS, ETC.
2D. STOCKS, BONDS, MUTUAL
FUNDS, ETC.
2E. REAL PROPERTY

(Not your home)

2F. ALL OTHER PROPERTY AND
ASSETS
VA FORM
XXX XXXX

21-0788

SUPERSEDES VA FORM 21-0788, MAR 2018.

Page 1

PART II - MONTHLY LIVING EXPENSES
Show your monthly living expenses, including any monthly installment payments. If you do not have expenses from a particular source, write
"0" or "none" in the space provided. Do not leave the space blank.
Note: If you are the veteran or surviving spouse, report only your expenses. If you are the claimant or are filing on behalf of the claimant(s),
report expenses for all persons for whom an apportionment is being claimed. If you are claiming an apportionment as the custodian of the
veteran's child or children, report your expenses and the expenses of the child(ren).
SOURCE
1A. RENT OR HOUSE PAYMENT

VETERAN OR
SURVIVING SPOUSE
$

CUSTODIAN
$

PERSON APPORTIONMENT
IS CLAIMED FOR
$

PERSON APPORTIONMENT
IS CLAIMED FOR
$

1B. FOOD
1C. UTILITIES Water, gas, electricity)
1D. TELEPHONE
1E. CLOTHING
1F. MEDICAL EXPENSES
1G. SCHOOL EXPENSES
1H. OTHER EXPENSES

(Show source)

1I. OTHER EXPENSES

(Show source)

PART III - REMARKS
8. REMARKS

PART IV - CERTIFICATION AND SIGNATURE
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
9. SIGNATURE OF VETERAN OR CLAIMANT (Required)

10. DATE SIGNED (MM/DD/YYYY)

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.
PRIVACY ACT INFORMATION - 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, 58VA 21/22/28, Compensation,
Pension, Education and Veteran Readiness and Employment Records - VA, published in the Federal Register.Your obligation to respond is required to obtain or retain
benefits. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered
confidential (38 U.S.C. 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 2900-0666, 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. 2900-0666 in any correspondence. Do not send your completed VA Form 21-0788 to this email address.
VA FORM 21-0788, XXX XXXX

Page 2