Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)

OMB 2900-0095

VA Form 21P-4165 (Formerly VA Form 21-4165) is used to gather information which is necessary to determine a claimant's countable annual income and available assets related to farm operations. Eligibility to income-based benefits cannot be determined without complete income information.

The latest form for Pension Claim Questionnaire for Farm Income (VA Form 21P-4165) expires 2022-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 21P-4165 Pension Claim Questionnaire for Farm Income Form
30-Day FRN.pdf Supplementary Document
60-Day FRN.pdf Supplementary Document
2900-0095, Supporting Statement (VAF 21P-4165).docx Supporting Statement A
Pension Claim Questionnaire for Farm Income Form

All Historical Document Collections

202204-2900-013 Approved without change	Revision of a currently approved collection	2022-07-19
201902-2900-003 Approved without change	Extension without change of a currently approved collection	2019-07-02
201604-2900-009 Approved with change	Revision of a currently approved collection	2016-07-26
201305-2900-015 Approved without change	Extension without change of a currently approved collection	2013-09-30
201009-2900-022 Approved without change	Extension without change of a currently approved collection	2010-12-23
200707-2900-029 Approved without change	Extension without change of a currently approved collection	2007-11-30
200410-2900-003 Approved without change	Extension without change of a currently approved collection	2004-10-22
200201-2900-001 Approved without change	Extension without change of a currently approved collection	2002-01-18
199811-2900-019 Approved without change	Reinstatement without change of a previously approved collection	1998-11-23
199508-2900-033 Withdrawn and continue	Extension without change of a currently approved collection	1995-08-28
199311-2900-004 Approved without change	Extension without change of a currently approved collection	1993-11-08
199008-2900-004 Approved without change	Extension without change of a currently approved collection	1990-08-10
198708-2900-007 Approved without change	Extension without change of a currently approved collection	1987-08-21
198407-2900-009 Approved without change	Revision of a currently approved collection	1984-07-30
198107-2900-045 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-07-17
198101-2900-028 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-01-29
198005-2900-004 Approved without change	Reinstatement without change of a previously approved collection	1980-05-07
197505-2900-002 Approved without change	Extension without change of a currently approved collection	1975-05-09