Form 21-0519s-1 Improved Pension Eligibility Verification Report (Surviving Spouse With Children)

FIRST MIDDLE LAST NAME OF VETERAN ( 7E WHEN DID THE INCOME CHANGE? (Show the dates you received any new income or the date income changed Line 1 of 2 ) ( 7E WHEN DID THE INCOME CHANGE? (Show the dates you received any new income or the date income changed Line 2 of 2 ) (1 A YOUR SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (1)I HAVE NOT MARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran's death ) (11 B Date Enter 2 digit month 2 digit day and 4 digit year ) (11 C Daytime TELEPHONE NUMBER (Include Area Code)) (11A SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing) This is a Protected Field ) (11C Evening TELEPHONE NUMBER (Include Area Code)) (1B VETERAN'S SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (1C YOUR DATE OF BIRTH (Month Day Year) Enter 2 digit month 2 digit day and 4 digit year ) (2)I REMARRIED ON (DATE) (3 A FULL NAME OF EACH CHILD (First middle initial last) Line 1 of 3 ) (3 A FULL NAME OF EACH CHILD (First middle initial last) Line 2 of 3 ) (3 A FULL NAME OF EACH CHILD (First middle initial last) Line 3 of 3 ) (3B Name of Child Line 1 of 2 ) (3B Name of Child Line 2 of 2 ) (4B SHOW THE DATE YOU ENTERED THE NURSING HOME Enter 2 digit month 2 digit day and 4 digit year ) (4C ENTER THE NAME COMPLETE ADDRESS AND TELEPHONE NUMBER OF NURSING HOME (Please Include ZIP Code) ) (6 (If "YES " write in the V A file number of the other benefit)) (7 A Monthly Income Child One Black Lung Benefits:) (7 A Monthly Income Child One Other 1 of 2:) (7 A Monthly Income Child One Other 2 of 2:) (7 A Monthly Income Child One Other Retirement:) (7 A Monthly Income Child One Show Source of Other 1 of 2 ) (7 A Monthly Income Child One Show Source of Other 2 of 2 ) (7 A Monthly Income Child One Social Security:) (7 A Monthly Income Child One U S Civill Service:) (7 A Monthly Income Child One U S Railroad Retirement:) (7 A Monthly Income Child One) (7 A Monthly Income Child Two Black Lung Benefits:) (7 A Monthly Income Child Two Other 1 of 2:) (7 A Monthly Income Child Two Other 2 of 2:) (7 A Monthly Income Child Two Other Retirement:) (7 A Monthly Income Child Two Show Source of Other 1 of 2 ) (7 A Monthly Income Child Two Show Source of Other 2 of 2 ) (7 A Monthly Income Child Two Social Security:) (7 A Monthly Income Child Two U S Civill Service:) (7 A Monthly Income Child Two U S Railroad Retirement:) (7 A Monthly Income Child Two) (7 A Monthly Income Surviving Spouse Black Lung Benefits:) (7 A Monthly Income Surviving Spouse Other 1 of 2) (7 A Monthly Income Surviving Spouse Other 2 of 2 ) (7 A Monthly Income Surviving Spouse Other Retirement:) (7 A Monthly Income Surviving Spouse Show Source of Other 1 of 2 ) (7 A Monthly Income Surviving Spouse Show Source of Other 2 of 2 ) (7 A Monthly Income Surviving Spouse Social Security:) (7 A Monthly Income Surviving Spouse U S Civil Service:) (7 A Monthly Income Surviving Spouse U S Railroad Retirement:) (7 B Annual Income Child One All Other (Show Source): 1 of 2) (7 B Annual Income Child One All Other (Show Source): 2 of 2 ) (7 B Annual Income Child One All Other (Show Source): 2 of 2) (7 B Annual Income Child One All Other: 1 of 2) (7 B Annual Income Child One All Other: 2 of 2) (7 B Annual Income Child One Gross Salary or Wages From All Employment:) (7 B Annual Income Child One Total Interest and Dividends:) (7 B Annual Income Child One) (7 B Annual Income Child Two All Other (Show Source): 1 of 2) (7 B Annual Income Child Two All Other (Show Source): 2 of 2) (7 B Annual Income Child Two All Other: 1 of 2) (7 B Annual Income Child Two All Other: 1 of 2) (7 B Annual Income Child Two All Other: 2 of 2) (7 B Annual Income Child Two Gross Salary or Wages From All Employment:) (7 B Annual Income Child Two Total Interest and Dividends:) (7 B Annual Income Child Two) (7 B Annual Income Surviving Spouse All Other (Show Source): 1 of 2) (7 B Annual Income Surviving Spouse All Other (Show Source): 2 of 2 ) (7 B Annual Income Surviving Spouse All Other: 1 of 2) (7 B Annual Income Surviving Spouse All Other: 2 of 2 ) (7 B Annual Income Surviving Spouse Gross Salary or Wages From All Employment:) (7 B Annual Income Surviving Spouse Total Interest and Dividends:) (7 B Annual Income: Child One From Date: Enter 2 digit month and 4 digit year ) (7 B Annual Income: Child One Thru Date: Enter 2 digit month and 4 digit year ) (7 B Annual Income: Child Two From Date: Enter 2 digit month and 4 digit year ) (7 B Annual Income: Child Two Thru Date: Enter 2 digit month and 4 digit year ) (7 B Annual Income: Surviving Spouse From Date: Enter 2 digit month and 4 digit year ) (7 B Annual Income: Surviving Spouse Thru Date: Enter 2 digit month and 4 digit year ) (7 G Net Worth Child One All Other Property:) (7 G Net Worth Child One Cash / Non Interest Bearing Bank Accounts:) (7 G Net Worth Child One Interest Bearing Bank Accounts:) (7 G Net Worth Child One IRA's KEOGH PLANS Excetra:) (7 G Net Worth Child One Real Property (Not your home):) (7 G Net Worth Child One Stocks Bonds Mutual Funds Excetra:) (7 G Net Worth Child One:) (7 G Net Worth Child Two All Other Property:) (7 G Net Worth Child Two Cash / Non Interest Bearing Bank Accounts:) (7 G Net Worth Child Two Interest Bearing Bank Accounts:) (7 G Net Worth Child Two IRA's KEOGH PLANS Excetra:) (7 G Net Worth Child Two Real Property (Not your home):) (7 G Net Worth Child Two Stocks Bonds Mutual Funds Excetra:) (7 G Net Worth Child Two:) (7 G Net Worth Surviving Spouse All Other Property:) (7 G Net Worth Surviving Spouse Cash / Non Interest Bearing Bank Accounts:) (7 G Net Worth Surviving Spouse Interest Bearing Bank Accounts:) (7 G Net Worth Surviving Spouse IRA's KEOGH PLANS Excetra:) (7 G Net Worth Surviving Spouse Real Property (Not your home):) (7 G Net Worth Surviving Spouse Stocks Bonds Mutual Funds Excetra:) (7D WHAT INCOME CHANGED? (Show what income changed for example wages city pension excetra) Line 1 of 2 ) (7D WHAT INCOME CHANGED? (Show what income changed for example wages city pension excetra) Line 2 of 2 ) (7F HOW DID INCOME CHANGE? (Tell what happened; for example quit work got raise received inheritance) Line 1 of 2 ) (7F HOW DID INCOME CHANGE? (Tell what happened; for example quit work got raise received inheritance) Line 2 of 2 ) (CHILD'S COMPLETE ADDRESS) (COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE) (Complete ONLY IF V A is currently excluding children's income on the grounds of hardship Show total family expenses expected for the next 12 months ) (DATE OF BIRTH (Month day year ) Enter 2 digit month 2 digit day and 4 digit year ) (DATE OF BIRTH (Month day year ) Enter 2 digit month 2 digit day and 4 digit year ) (Date Show the date your marriage ended Enter 2 digit month 2 digit day and 4 digit year ) (Date you married your current spouse Enter 2 digit month 2 digit day and 4 digit year ) (DATE) (First middle initial last) (FIRST MIDDLE LAST NAME OF SURVIVING SPOUSE) (FIRST MIDDLE LAST NAME OF VETERAN ) (If "YES " complete Items 4B through 4D If "NO " go to Item 5 ) (If "YES " complete Items 7D through 7F If "NO " go to Item 7G )NOYES7D WHAT INCOME CHANGED? (If "YES " write in the VA file number of the other benefit)NOYES (Mo day yr ) (MONTHLY AMOUNT YOU CONTRIBUTE TO CHILD'S SUPPORT) (NAME OF PERSON CHILD LIVES WITH (If Applicable)) (Show amounts paid by you during the last 12 months DO NOT REPORT CHILDRENS' EXPENSES ) (Show what income changed for example wages city (Showthe dates you received any new income orthe date income changed) (SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (Surviving Spouse with Children)9S (Tell what happened; for example quit work got (V A FILE NUMBER) (V A REGIONAL OFFICE RETURN ADDRESS) (You remarried but you are not currently married Show the date your latest marriage ended ) 10 FAMILY MAINTENANCE (HARDSHIP) EXPENSES FOR NEXT 12 MONTHS (Read Paragraph 8 of the EVR Instructions) 11A SIGNATURE OF PAYEE (Read Paragraph 9 of the EVR Instructions before signing) 11B DATE 11C TELEPHONE NUMBERS (Include Area Code) 12 months $ 1A YOUR SOCIAL SECURITY NUMBER 1B VETERAN'S SOCIAL SECURITY NUMBER 1C YOUR DATE OF BIRTH (Month Day Year) 2 MARITAL STATUS (Check only one box) 21 0519S 1 3A UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions) 3B UNMARRIED DEPENDENT CHILDREN LISTED IN 3A WHO DO NOT LIVE WITH YOUNAME OF CHILDCHILD'S COMPLETE ADDRESSNAME OF PERSON CHILD 4A ARE YOU A PATIENT IN A NURSING HOME? 4B SHOW THE DATE YOU ENTERED THE NURSING HOME 4C ENTER THE NAME COMPLETE ADDRESS AND 4D DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES? 5 DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS? 6 DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN PARENT OR SURVIVING SPOUSE? 7A MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions) 7B ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions) 7C DID ANY INCOME CHANGE (Increase/Decrease) DURING THE PAST 12 MONTHS? ( Answer "NO" if there were no income changes or if the only 7E WHEN DID THE INCOME CHANGE? 7F HOW DID INCOME CHANGE? 7G NET WORTH (Read Paragraph 5 of the EVR Instructions) 8 FAMILY MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions) 9 SURVIVING SPOUSE'S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR Instructions) ALL OTHER (Show Source) ALL OTHER PROPERTY AND I AM STILL MARRIED (You married after the veteran's death and you are currently ATTENDING BIRTH BLACK LUNG BENEFITS CASH/NON INTEREST BEARING BANK ACCOUNTS 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 CHILD CHILD: CHILD: 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 COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE Complete ONLY IF VA is currently excluding children's income on the grounds of hardship Show total family expenses expected for the next CONTRIBUTE TO CHILD'S DATE OF DAYTIME December) income in the left hand column and current calendar year income in the right hand column Department of Veterans Affairs DIVIDENDS Enter the day you married your current spouse ) EVENING FEB 2012 FIRST MIDDLE LAST NAME OF SURVIVING SPOUSE FROM ALL EMPLOYMENT FROM: FROM: FROM: FULL NAME OF EACH GROSS MONTHLY AMOUNTS (If no income was received from a particular source write "0" or "none " VA WILL INTERPRET A BLANK SPACE AS "NONE" OR "0 ") GROSS SALARY OR WAGES HELPLESS FOR I REMARRIED AFTER THE VETERAN DIED BUT THE MARRIAGE ENDED BY DEATH OR DIVORCE ON (3) If no income was received from a particular source write "0" or "none " VA WILL INTERPRET A BLANK SPACE AS "NONE" OR "0 " IMPORTANT Please read the enclosed EVR Instructions (VA Form 21 0510) prior to completing this form IMPROVED PENSION ELIGIBILITY Include ZIP Code) Instructions indicates that you should report medical expenses use VA Form 21 8416 Medical Expense Report If you are using this form as a supplement to a pending INTEREST BEARING BANK ACCOUNTS IRA'S KEOGH PLANS ETC knowing it is false or fraudulent acceptance of any payment to which you are not entitled LIVES WITH (If Applicable) married MENTAL OR MONTHLY AMOUNT YOU 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 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 NOYES NOYES NUMBERPLEASE CHECK ONE (X) OMB Approved No 2900 0101 ONE TIME income ) OTHER (Show Source) OTHER RETIREMENT 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 pension etc ) PERMANENTLY PHYSICAL REASONS raise received inheritance) REAL PROPERTY (Not your home) Respondent Burden : 40 minutes SCHOOLANY AGE Show amounts paid by you during the last 12 months DO NOT REPORT CHILDRENS' EXPENSES $ SOCIAL SECURITY SOURCESURVIVING SPOUSE SOURCESURVIVING SPOUSE CHILD: STOCKS BONDS MUTUAL FUNDS ETC SUPPORT TELEPHONE NUMBER OF NURSING HOME (Please THRU: THRU: THRU: TOTAL INTEREST AND U S CIVIL SERVICE U S RAILROAD RETIREMENT UNDER 18 UNDER 23 AND VA FILE NUMBER VA FORM 21 0519S 1 FEB 2012 VA FORM SUPERSEDES VA FORM 21 0519S 1 JUN 2004 (Continued on Next Page) VA REGIONAL OFFICE RETURN ADDRESS VERIFICATION REPORT WHICH WILL NOT BE USED YEARS OF AGEOVER 18 AND