Va Form 21-0512s-1 - Old Law And Section 306 Eligibility Verification Report (Surviving Spouse)

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OMB Approved No. 2900-0101
Respondent Burden: 30 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN
OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
2S
(SURVIVING SPOUSE)
FIRST, MIDDLE, LAST NAME OF SURVIVING SPOUSE
VA FILE NUMBER
COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21-0510) before completing this form. This form is used by
surviving spouses receiving Old Law or Section 306 Pension. If you have been receiving a fixed rate of pension since 1960, you receive
Old Law Pension. If you have been receiving a fixed rate of pension since 1978, you receive Section 306 Pension. If you receive Old
Law Pension, do not complete Item 7G, Net Worth, and Item 8, Family Medical Expenses. If you receive Section 306 Pension, complete
all items.
1A. VETERAN'S SOCIAL SECURITY NUMBER
1B. YOUR SOCIAL SECURITY NUMBER
1C. YOUR DATE OF BIRTH (Mo., day, yr.)
2. MARITAL STATUS (Check one box)
(1)
I HAVE NOT REMARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran's death)
(2)
I REMARRIED ON
(Date) AND I AM STILL MARRIED (You married after the veteran's death and you are
currently married. Enter the date you married your current spouse.)
(3)
I REMARRIED AFTER VETERAN DIED BUT MARRIAGE ENDED BY DEATH OR DIVORCE ON
(Date)
(You remarried but you are not currently married.) Show the date your latest marriage ended.)
3A. NUMBER OF UNMARRIED DEPENDENT CHILDREN
3B. AMOUNT CONTRIBUTED
(See Paragraph 1 of the EVR Instructions)
DURING PAST 12 MONTHS
TO CHILDREN NOT IN YOUR CUSTODY
IN YOUR CUSTODY
NOT IN YOUR CUSTODY
$
4A. ARE YOU A PATIENT IN A NURSING HOME? (If "YES," Complete Items 4B thru 4D) If "NO," go to Item 5.)
YES
NO
4C. ENTER THE NAME, COMPLETE ADDRESS, AND
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
TELEPHONE NUMBER OF NURSING HOME
(Please include ZIP Code)
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?
YES
NO
5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE LAST 12 MONTHS?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
(If you checked "YES," write in the VA File number of the other benefit)
YES
NO
21-0512s-1
VA FORM
SUPERSEDES VA FORMS 21-0511S-1, AUG 2000 AND
(Continued on Reverse)
JUN 2004
21-0512S-1, JUN 2002, WHICH WILL NOT BE USED.

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