Va Form 21-0788 - Information Regarding Apportionment Of Beneficiary'S Award

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OMB Approved No. 2900-0666
Respondent Burden: 30 minutes
Expiration Date: 11/30/2017
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)
INFORMATION REGARDING APPORTIONMENT OF BENEFICIARY'S AWARD
INSTRUCTIONS: 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. Print all answers
clearly. If an answer is "none" or "0," write that or line through the space provided. 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 form.
IMPORTANT: 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)). Additional guidance on when VA recognizes marriages is available at
1. FIRST, MIDDLE, LAST NAME OF VETERAN
2. VA FILE NUMBER
C/CSS-
(If other than veteran)
(Number and street or rural route, city or
3A. FIRST, MIDDLE, LAST NAME OF PERSON COMPLETING THIS FORM
3B. MAILING ADDRESS
P.O., State and ZIP Code)
(Include Area Code)
(If applicable)
3C. TELEPHONE NUMBER
3D. E-MAIL ADDRESS
Daytime
Evening
(List first, middle, and last names)
4B. WHAT IS HIS/HER RELATIONSHIP TO THE
4A. WHO ARE YOU REQUESTING AN APPORTIONMENT FOR?
VETERAN?
5A. HOW MUCH IS THE VETERAN OR VETERAN'S SURVIVING SPOUSE CONTRIBUTING TO THE PERSON(S)
5B. HOW OFTEN ARE THE CONTRIBUTIONS MADE?
FOR WHOM AN APPORTIONMENT IS BEING CLAIMED?
$
6. IF THE SPOUSE IS CLAIMING AN APPORTIONMENT, IS HE/SHE LIVING WITH ANOTHER PERSON AND
7. HAS THE VETERAN'S CHILD(REN) BEEN
HOLDING HIMSELF/HERSELF OUT OPENLY TO THE PUBLIC AS THE SPOUSE OF THE OTHER PERSON?
LEGALLY ADOPTED BY ANOTHER PERSON?
(If "Yes," provide an explanation)
YES
NO
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
VETERAN OR
PERSON APPORTIONMENT IS
PERSON APPORTIONMENT
SOURCE
CUSTODIAN
SURVIVING SPOUSE
CLAIMED FOR
IS CLAIMED FOR
1A. GROSS WAGES FROM ALL
EMPLOYMENT
$
$
$
$
1B. SOCIAL SECURITY
1C. RETIREMENT OR ANNUITIES
1D. SUPPLEMENTAL SECURITY
INCOME (SSI) / PUBLIC ASSISTANCE
(Show source)
1E. OTHER INCOME
(Show source)
1F. OTHER INCOME
NET WORTH
VETERAN OR
PERSON APPORTIONMENT IS
PERSON APPORTIONMENT
SOURCE
CUSTODIAN
SURVIVING SPOUSE
CLAIMED FOR
IS CLAIMED FOR
2A. CASH/NON-INTEREST-BEARING
BANK ACCOUNTS
$
$
$
$
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
SUPERSEDES VA FORM 21-0788, JUN 2014,
21-0788
NOV 2014
WHICH WILL NOT BE USED.

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