Va Form 21-0516-1 - Improved Pension Eligibility Verification Report (Veteran With No Children)

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OMB Control No. 2900-0101
Respondent Burden: 30 minutes
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN
IMPROVED PENSION ELIGIBILITY
YOUR COMPLETE MAILING ADDRESS
VERIFICATION REPORT
6
(VETERAN WITH NO CHILDREN)
VA FILE NUMBER
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER
1B. YOUR SPOUSE'S SOCIAL SECURITY NUMBER
(Mo., day, yr.)
1C. FIRST, MIDDLE, LAST NAME OF SPOUSE
1D. SPOUSE'S DATE OF BIRTH
(Check only one box)
2. MARITAL STATUS
(You are legally married and you live with your spouse or are separated for medical reasons.)
MARRIED-LIVING WITH SPOUSE
(1)
(You are legally married but estranged from your spouse.)
(2)
MARRIED-NOT LIVING WITH SPOUSE
Show the amount you contributed to your spouse's support during the last 12 months $
If you separated within the last 12 months, show the date of separation
(You have never married or are now divorced or widowed.)
(3)
NOT MARRIED
If your marriage ended within the last 12 months, show the date of divorce or death.
(See Paragraph 1 of the EVR Instructions, VA Form 21-0510)
3. NUMBER OF UNMARRIED, DEPENDENT CHILDREN
IN YOUR CUSTODY
NOT IN YOUR CUSTODY
AMOUNT CONTRIBUTED DURING PAST 12 MONTHS TO CHILDREN NOT IN YOUR CUSTODY
$
4A. ARE YOU A PATIENT IN A NURSING HOME?
4C. ENTER THE NAME, COMPLETE ADDRESS, AND
TELEPHONE NUMBER OF NURSING HOME
If "Yes," Complete Items 4B thru 4D. If "No," go to Item 5.)
(
YES
NO
(Please include Zip Code)
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?
YES
NO
4E. SHOW THE DATE YOUR MEDICAID COVERAGE STARTED
5. DID EITHER YOU OR YOUR SPOUSE RECEIVE ANY WAGES OR WERE EITHER OF YOU EMPLOYED AT ANY TIME DURING THE
PAST 12 MONTHS?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
(If "Yes," write in the VA file number of the other benefit)
YES
NO
21-0516-1
SUPERSEDES VA FORM 21-0516-1, JUN 2004,
(Continued on Next Page)
VA FORM
FEB 2012
WHICH WILL NOT BE USED.

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