Va Form 21-527ez - Application For Pension - Department Of Veteran Affairs Page 3
Download a blank fillable Va Form 21-527ez - Application For Pension - Department Of Veteran Affairs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 21-527ez - Application For Pension - Department Of Veteran Affairs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4SECTION VII: INCOME VERIFICATION - NET WORTH
(MUST COMPLETE)
25. NET WORTH (DO NOT LEAVE ANY ITEMS BLANK. If your household has no net worth in a particular source, write "0" or "none")
Report total net worth for your household. You must report your net worth and the net worth of your dependents (spouse, child, etc.), if any. Identify the
specific owner for each net worth source, yourself or another person in your household, as applicable.
SOURCE
AMOUNT
OWNER
SOURCE
AMOUNT
OWNER
CASH/NON-INTEREST
REAL PROPERTY
BEARING BANK
(Not your home, vehicle,
ACCOUNTS
furniture, or clothing)
$
$
INTEREST-BEARING
ALL OTHER PROPERTY
BANK ACCOUNTS
(Please write source)
$
$
IRA'S, KEOGH PLANS,
ALL OTHER PROPERTY
ETC.
(Please write source)
$
$
OTHER (Provide source)
STOCKS, BONDS,
MUTUAL FUNDS, ETC.
$
$
SECTION VIII: INCOME VERIFICATION - MONTHLY INCOME (MUST COMPLETE
)
26. GROSS MONTHLY INCOME (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")
Report total monthly income for your household. You must report your income and the income of your dependents (spouse, child, etc.), if any. Identify
the specific income recipient for each income source, yourself or another person in your household, as applicable.
SOURCE
AMOUNT
RECIPIENT
SOURCE
AMOUNT
RECIPIENT
SOCIAL SECURITY
SERVICE RETIREMENT
$
$
SUPPLEMENTAL SECURITY
SOCIAL SECURITY
INCOME (SSI)/PUBLIC
$
$
ASSISTANCE
OTHER (Provide source)
U.S. CIVIL SERVICE
$
$
OTHER (Provide source)
U.S. RAILROAD
RETIREMENT
$
$
OTHER (Provide source)
BLACK LUNG
BENEFITS
$
$
SECTION IX: EXPECTED INCOME
(MUST COMPLETE)
27. EXPECTED INCOME - NEXT 12 MONTHS (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")
Report expected total household income for the next 12 months. You must report your expected income and the expected income of your dependents
(spouse, child, etc.), if any. Identify the specific income recipient for each income source, yourself or another person in your household, as applicable.
SOURCE
AMOUNT
RECIPIENT
SOURCE
AMOUNT
RECIPIENT
OTHER INCOME
GROSS WAGES AND
EXPECTED (Provide source)
SALARY
$
$
OTHER INCOME
GROSS WAGES AND
EXPECTED (Provide source)
SALARY
$
$
OTHER INCOME
TOTAL DIVIDENDS AND
EXPECTED (Provide source)
INTEREST
$
$
SECTION X: MEDICAL, LEGAL, OR OTHER UNREIMBURSED EXPENSES
(MUST COMPLETE)
28. MEDICAL, LEGAL, OR OTHER UNREIMBURSED EXPENSES (IF NONE WRITE "0" OR "NONE")
Report your family medical expenses and certain other expenses actually paid by you that may be deductible from your income. Show
the amount of unreimbursed medical expenses, including the Medicare deduction you paid for yourself or relatives who are members of
your household. Also, show unreimbursed last illness and burial expenses and educational or vocational rehabilitation expenses you
paid. Last illness and burial expenses are unreimbursed amounts paid by you for the last illness and burial of a spouse or child at any
time prior to the end of the year following the year of death. Educational or vocational rehabilitation expenses are amounts paid for
courses of education, including tuition, fees, and materials. Show medical, legal or other expenses you paid because of a disability for
which civilian disability benefits have been awarded. When determining your income, we may be able to deduct them from the disability
benefits for the year in which the expenses are paid. Do not include any expenses for which you were reimbursed.
PURPOSE
RELATIONSHIP OF PERSON
DATE PAID
PAID TO (Name of doctor,
AMOUNT PAID BY YOU
(Doctor's fees, hospital charges, attorney fees, tuition,
FOR WHOM EXPENSES PAID
(mm/dd/yy)
hospital, pharmacy, etc.)
education materials, etc.)
(Spouse, child, etc.)
$
$
$
$
VA FORM 21-527EZ, JUN 2014
Page 7
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21-4182 - Application For Dependency And Indemnity Compensation Or Death Pension (including Accrued Benefits And Death Compensation Where Applicable) From The Department Of Veterans Affairs
Legal
Related Categories
Parent category: Legal