Va Form 21p-534ez - Notice To Survivor Of Evidence Necessary To Substantiate A Claim For Dependency And Indemnity Compensation, Death Pension, And/or Accrued Benefits Page 9

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SECTION VII: NET WORTH

(COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)

(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)

37. 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. Identify the specific owner for each net worth source, yourself or another person in your household, as applicable.

If you are the custodian filing for a child of the veteran, you must report your net worth and the child's net worth, if any.

SOURCE

AMOUNT

OWNER

SOURCE

AMOUNT

OWNER

CASH/NON-INTEREST

REAL PROPERTY

BEARING BANK

(Not your home, vehicle,

ACCOUNTS

furniture, or clothing)

OTHER PROPERTY

INTEREST-BEARING

(Provide source)

BANK ACCOUNTS

OTHER PROPERTY

IRA'S, KEOGH PLANS,

(Provide source)

ETC.

OTHER (Provide source)

STOCKS, BONDS,

MUTUAL FUNDS, ETC.

SECTION VIII: GROSS MONTHLY INCOME

(COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)

(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)

38. 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. Identify the specific income recipient for each income source, yourself or another person in your household,

as applicable. If you are the custodian filing for a child of the veteran, you must report your income and the child's income, if any.

SOURCE

AMOUNT

RECIPIENT

SOURCE

AMOUNT

RECIPIENT

SERVICE RETIREMENT/

SOCIAL SECURITY

SURVIVOR BENEFIT PLAN

(SBP) ANNUITY

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

(COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)

(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)

39. 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 12 month period following the veteran's death. If the claim is filed more than one year after the veteran died, report

the expected total household income for the 12 month period from the date you sign this application. Identify the specific income recipient for each income source,

yourself or another person in your household, as applicable. If you are the custodian filing for a child of the veteran, you must report your expected income

and the child's expected income, if any.

SOURCE

AMOUNT

RECIPIENT

SOURCE

AMOUNT

RECIPIENT

OTHER INCOME EXPECTED

GROSS WAGES AND

(Provide source)

SALARY

OTHER INCOME EXPECTED

GROSS WAGES AND

(Provide source)

SALARY

OTHER INCOME EXPECTED

TOTAL DIVIDENDS AND

(Provide source)

INTEREST

SECTION X: MEDICAL, LAST ILLNESS, BURIAL, OR OTHER UNREIMBURSED EXPENSES

(COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)

(Skip to Section XI if you are NOT claiming death pension or parents DIC)

40. MEDICAL, LAST ILLNESS, BURIAL, OR OTHER UNREIMBURSED EXPENSES

Family medical expenses and certain other expenses actually paid by you may be deductible from your income. Show the amount of any continuing

family medical expenses such as the monthly Medicare deduction or nursing home costs you pay. 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 veteran's or his/her child's last illness and burial and the veteran's just debts. Educational or vocational rehabilitation expenses are amounts paid for

courses of education, including tuition, fees, and materials. Do not include any expenses for which you were reimbursed. If you receive reimbursement

after you have filed this claim, promptly advise the VA office handling your claim.

PURPOSE

RELATIONSHIP OF PERSON

DATE PAID

PAID TO (Name of nursing home,

AMOUNT PAID BY YOU

(Medicare deduction, nursing home costs,

FOR WHOM EXPENSES PAID

(mm/dd/yyyy)

hospital, funeral home, etc.)

burial expenses, etc.)