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

(Not your home) 1A RENT OR HOUSE PAYMENT 3C TELEPHONE NUMBER(Include Area Code) Evening I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief Report all income and net worth Report the gross amounts before you take out deductions for taxes insurance etc If you do not (1 FIRST MIDDLE LAST NAME OF VETERAN) (1 SIGNATURE OF VETERAN OR CLAIMANT THIS IS A PROTECTED FIELD ) (2 DATE SIGNED Enter 2 digit month 2 digit day and 4 digit year ) (2 V A FILE NUMBER) (3 A FIRST MIDDLE LAST NAME OF PERSON COMPLETING THIS FORM (If other than veteran)) (3B MAILING ADDRESS (Number and street or rural route city or P O State and ZIP Code)) (3D E MAIL ADDRESS (If applicable)) (4 A WHO ARE YOU REQUESTING AN APPORTIONMENT FOR? (List first middle and last names)) (4B WHAT IS HIS/HER RELATIONSHIP TO THE VETERAN?) (5 A HOW MUCH IS THE VETERAN OR VETERAN'S SURVIVING SPOUSE CONTRIBUTING TO THE PERSON(S) (5B HOW OFTEN ARE THE CONTRIBUTIONS MADE?) (CUSTODIAN ALL OTHER PROPERTY AND ASSETS NET WORTH) (CUSTODIAN CASH / NON INTEREST BEARING BANK ACCOUNTS NET WORTH) (CUSTODIAN CLOTHING MONTHLY EXPENSE) (CUSTODIAN FOOD MONTHLY EXPENSE) (CUSTODIAN GROSS WAGES FROM ALL EMPLOYMENT MONTHLY INCOME) (CUSTODIAN I R A S KEOGH PLANS ETC NET WORTH) (CUSTODIAN INTEREST BEARING BANK ACCOUNTS NET WORTH) (CUSTODIAN MEDICAL MONTHLY EXPENSE) (CUSTODIAN OTHER MONTHLY EXPENSE 1 of 2) (CUSTODIAN OTHER MONTHLY EXPENSE 2 of 2) (CUSTODIAN OTHER MONTHLY INCOME 1 of 2) (CUSTODIAN OTHER MONTHLY INCOME 2 of 2) (CUSTODIAN REAL PROPERTY (Not your home) NET WORTH) (CUSTODIAN RENT OR HOUSE PAYMENT MONTHLY EXPENSE) (CUSTODIAN RETIREMENT OR ANNUITIES MONTHLY INCOME) (CUSTODIAN SCHOOL MONTHLY EXPENSE) (CUSTODIAN SOCIAL SECURITY MONTHLY INCOME) (CUSTODIAN STOCKS BONDS MUTUAL (CUSTODIAN SUPPLEMENTAL SECURITY (CUSTODIAN TELEPHONE MONTHLY EXPENSE) (CUSTODIAN UTILITIES (Water gas electricity) MONTHLY EXPENSE) (Daytime Phone Number (Include Area Code)) (DO NOT WRITE IN THIS SPACE) (Evening Phone Number (Include Area Code)) (If "Yes " provide an explanation) (PERSON APPORTIONMENT IS CLAIMED FOR ALL OTHER PROPERTY AND ASSETS NET WORTH) (PERSON APPORTIONMENT IS CLAIMED FOR CASH / NON INTEREST BEARING (PERSON APPORTIONMENT IS CLAIMED FOR CLOTHING MONTHLY EXPENSE) (PERSON APPORTIONMENT IS CLAIMED FOR FOOD MONTHLY EXPENSE) (PERSON APPORTIONMENT IS CLAIMED FOR GROSS WAGES FROM ALL (PERSON APPORTIONMENT IS CLAIMED FOR I R A S KEOGH PLANS ETC NET WORTH) (PERSON APPORTIONMENT IS CLAIMED FOR INTEREST BEARING BANK ACCOUNTS NET WORTH) (PERSON APPORTIONMENT IS CLAIMED FOR MEDICAL MONTHLY EXPENSE) (PERSON APPORTIONMENT IS CLAIMED FOR OTHER MONTHLY EXPENSE 1 of 2) (PERSON APPORTIONMENT IS CLAIMED FOR OTHER MONTHLY EXPENSE 2 of 2) (PERSON APPORTIONMENT IS CLAIMED FOR OTHER MONTHLY INCOME 1 of 2) (PERSON APPORTIONMENT IS CLAIMED FOR OTHER MONTHLY INCOME 2 of 2) (PERSON APPORTIONMENT IS CLAIMED FOR REAL PROPERTY (Not your home) ) (PERSON APPORTIONMENT IS CLAIMED FOR REAL PROPERTY (Not your home) NET WORTH) (PERSON APPORTIONMENT IS CLAIMED FOR RENT OR HOUSE PAYMENT MONTHLY EXPENSE) (PERSON APPORTIONMENT IS CLAIMED FOR RETIREMENT OR ANNUITIES MONTHLY INCOME) (PERSON APPORTIONMENT IS CLAIMED FOR SCHOOL MONTHLY EXPENSE) (PERSON APPORTIONMENT IS CLAIMED FOR SOCIAL SECURITY MONTHLY INCOME) (PERSON APPORTIONMENT IS CLAIMED FOR STOCKS BODNS MUTUAL FUNDS ETC NET WORTH) (PERSON APPORTIONMENT IS CLAIMED FOR SUPPLEMENTAL SECURITY INCOME (S S I) / PUBLIC ASSISTANCE MONTHLY INCOME) (PERSON APPORTIONMENT IS CLAIMED FOR TELEPHONE MONTHLY EXPENSE) (PERSON APPORTIONMENT IS CLAIMED FOR UTILITIES (Water gas electricity) MONTHLY EXPENSE) (Show source ) (Show source) (Show Source) (VA DATE STAMP) (VETERAN OR SURVIVING SPOUSE ALL OTHER PROPERTY AND ASSETS NET WORTH) (VETERAN OR SURVIVING SPOUSE CASH / NON INTEREST BEARING (VETERAN OR SURVIVING SPOUSE CLOTHING MONTHLY EXPENSE) (VETERAN OR SURVIVING SPOUSE FOOD MONTHLY EXPENSE) (VETERAN OR SURVIVING SPOUSE GROSS WAGES FROM ALL EMPLOYMENT MONTHLY INCOME) (VETERAN OR SURVIVING SPOUSE I R A S KEOGH PLANS ETC NET WORTH) (VETERAN OR SURVIVING SPOUSE INTEREST BEARING BANK (VETERAN OR SURVIVING SPOUSE MEDICAL MONTHLY EXPENSE) (VETERAN OR SURVIVING SPOUSE OTHER MONTHLY EXPENSE 1 of 2) (VETERAN OR SURVIVING SPOUSE OTHER MONTHLY EXPENSE 2 of 2) (VETERAN OR SURVIVING SPOUSE OTHER MONTHLY INCOME 1 of 2) (VETERAN OR SURVIVING SPOUSE OTHER MONTHLY INCOME 2 of 2) (VETERAN OR SURVIVING SPOUSE REAL PROPERTY (Not your home) NET WORTH) (VETERAN OR SURVIVING SPOUSE RENT OR HOUSE PAYMENT MONTHLY EXPENSE) (VETERAN OR SURVIVING SPOUSE RETIREMENT OR ANNUITIES MONTHLY INCOME) (VETERAN OR SURVIVING SPOUSE SCHOOL MONTHLY EXPENSE) (VETERAN OR SURVIVING SPOUSE SOCIAL SECURITY MONTHLY INCOME) (VETERAN OR SURVIVING SPOUSE STOCKS BONDS MUTUAL (VETERAN OR SURVIVING SPOUSE SUPPLEMENTAL SECURITY INCOME (S S I) / PUBLIC ASSISTANCE MONTHLY INCOME) (VETERAN OR SURVIVING SPOUSE TELEPHONE MONTHLY EXPENSE) (VETERAN OR SURVIVING SPOUSE UTILITIES (Water gas electricity) MONTHLY EXPENSE) (Water gas electricity) 1 FIRST MIDDLE LAST NAME OF VETERAN 1 SIGNATURE OF VETERAN OR CLAIMANT 1B FOOD 1B SOCIAL SECURITY 1C RETIREMENT OR ANNUITIES 1C UTILITIES 1D SUPPLEMENTAL SECURITY 1D TELEPHONE 1E CLOTHING 1F MEDICAL EXPENSES 1F OTHER INCOME (Show source) 1G SCHOOL EXPENSES 1H OTHER EXPENSES 1I OTHER EXPENSES 2 DATE SIGNED 2 VA FILE NUMBER 21 0788 2A CASH/NON INTEREST BEARING 2B INTEREST BEARING BANK 2C IRAS KEOGH PLANS ETC 2D STOCKS BONDS MUTUAL 2E REAL PROPERTY 2F ALL OTHER PROPERTY AND 3A FIRST MIDDLE LAST NAME OF PERSON COMPLETING THIS FORM (If other than veteran) 3B MAILING ADDRESS (Number and street or rural route city or 3D E MAIL ADDRESS (If applicable) 4A WHO ARE YOU REQUESTING AN APPORTIONMENT FOR? (List first middle and last names) 4B WHAT IS HIS/HER RELATIONSHIP TO THE 5A HOW MUCH IS THE VETERAN OR VETERAN'S SURVIVING SPOUSE CONTRIBUTING TO THE PERSON(S) 5B HOW OFTEN ARE THE CONTRIBUTIONS MADE? 6 IF THE SPOUSE IS CLAIMING AN APPORTIONMENT IS HE/SHE LIVING WITH ANOTHER PERSON AND 7 HAS THE VETERAN'S CHILD(REN) BEEN ACCOUNTS ACCOUNTS NET WORTH) administration) as identified in the VA system of records 58VA 21/22/28 Compensation Pension Education and Vocational Rehabilitation and as the custodian of the veteran's child or children report your expenses and the expenses of the child(ren) 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) ASSETS attachments to the form BANK ACCOUNTS BANK ACCOUNTS NET WORTH) BANK ACCOUNTS NET WORTH) be located on the OMB Internet Page at www whitehouse gov/omb/library/OMBINV VA EPA html#VA If desired you can call 1 800 827 1000 to C/CSS claimant(s) report all income and net worth for all persons for whom an apportionment is being claimed If you are claiming an apportionment claimant(s) report expenses for all persons for whom an apportionment is being claimed If you are claiming an apportionment CLAIMED FOR CLAIMED FOR clearly If an answer is "none" or "0 " write that or line through the space provided For additional space attach a separate sheet communications epidemiological or research studies the collection of money owed to the United States litigation in which the United States is a CUSTODIAN Daytime dependent parent A surviving spouse's award may also be apportioned for the veteran's child or children Print all answers EMPLOYMENT EMPLOYMENT MONTHLY INCOME) Employment Records VA published in the Federal Register FOR WHOM AN APPORTIONMENT IS BEING CLAIMED? FOR WHOM AN APPORTIONMENT IS BEING CLAIMED?) FUNDS ETC FUNDS ETC NET WORTH) get information on where to send comments or suggestions about this form HOLDING HIMSELF/HERSELF OUT OPENLY TO THE PUBLIC AS THE SPOUSE OF THE OTHER PERSON? INCOME (S S I) / PUBLIC ASSISTANCE MONTHLY INCOME) INCOME (SSI) / PUBLIC ASSISTANCE1E OTHER INCOME (Show source) indicating the item number to which the answers apply Make sure to write the veteran's name and VA claim number on any INFORMATION REGARDING APPORTIONMENT OF BENEFICIARY'S AWARD instructions find the information and complete this form VA cannot conduct or sponsor a collection of information unless a valid OMB control INSTRUCTIONS: All or part of a veteran's disability award may be apportioned (paid) to the veteran's spouse child or IS CLAIMED FOR LEGALLY ADOPTED BY ANOTHER PERSON? maximum benefits under the law The responses you submit are considered confidential (38 U S C 5701) Information submitted is subject to MAY 2009WHICH WILL NOT BE USED MONTHLY INCOME NET WORTHVETERAN OR 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 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 number is displayed You are not required to respond to a collection of information if this number is not displayed Valid OMB control numbers can of a material fact knowing it is false or fraudulent acceptance of any payment to which you are not entitled OMB Approved No 2900 0666 P O State and ZIP Code) PART I INCOME AND NET WORTH PART II MONTHLY LIVING EXPENSES PART III CERTIFICATION AND SIGNATURE party or has an interest the administration of VA programs and delivery of VA benefits verification of identity and status and personnel PENALTY The law provides severe penalties which include fine or imprisonment or both for the willful submission of anystatement or evidence PERSON APPORTIONMENT PERSON APPORTIONMENT IS PERSON APPORTIONMENT IS PRIVACY ACT INFORMATION The VA will not disclose information collected on this form to any source other than what has been authorized receive income or net worth from a particular source write "0" or "none" in the space provided Do not leave the space blank RESPONDENT BURDEN We need this information to determine whether an apportionment of VA disability or death benefits may be made (38 U Respondent Burden: 30 minutes S C 5307) Title 38 United States Code allows us to ask for this information We estimate that you will need an average of 30 minutes to review the Show your monthly living expenses including any monthly installment payments If you do not have expenses from a particular SOURCE source write "0" or "none" in the space provided Do not leave the space blank SOURCESURVIVING SPOUSEIS CLAIMED FORCLAIMED FORCUSTODIAN1A GROSS WAGES FROM ALL SURVIVING SPOUSE 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 VA FORM 21 0788 MAY 2009 VA FORM SUPERSEDES VA FORM 21 0788 JAN 2005 verification through computer matching programs with other agencies VETERAN OR VETERAN? Your obligation to respond is required to obtain or retain benefits The requested information is considered relevant and necessary to determine