Va Form 21-0788 - Information Regarding Apportionment Of Beneficiary'S Award Page 2

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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).

VETERAN OR

PERSON APPORTIONMENT

SOURCE

CUSTODIAN

SURVIVING SPOUSE

IS CLAIMED FOR

1A. RENT OR HOUSE PAYMENT

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 - CERTIFICATION AND SIGNATURE

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.

1. SIGNATURE OF VETERAN OR CLAIMANT

2. DATE SIGNED

PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of anystatement 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 Vocational Rehabilitation 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 - We need this information to determine whether an apportionment of VA disability or death benefits may be made (38 U.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 instructions, find the information,

and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control 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 be located on the OMB Internet Page at

If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-0788, NOV 2014