Va Form 21-0512s-1 - Old Law And Section 306 Eligibility Verification Report (Surviving Spouse) Page 2

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REPORT OF INCOME AND NET WORTH

If you have no income or net worth from a particular source, write "0"or "none". DO NOT LEAVE ANY ITEMS BLANK.

7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)

SOURCE

GROSS MONTHLY AMOUNTS

SOCIAL SECURITY

U.S. CIVIL SERVICE

U.S. RAILROAD RETIREMENT

MILITARY RETIREMENT

BLACK LUNG BENEFITS

SUPPLEMENTAL SECURITY INCOME

(SSI)/PUBLIC ASSISTANCE

OTHER MONTHLY INCOME

(Show Source)

7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)

If no income was received from a particular source, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.

SOURCE

LAST YEAR

THIS YEAR

GROSS WAGES FROM ALL EMPLOYMENT

INTEREST AND DIVIDENDS

ALL OTHER (Show Source)

7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE PAST 12 MONTHS? (Answer "NO" if there were no income changes or if the

only change was a Social Security/VA cost-of-living adjustment. Answer "YES" if there were any other income changes or if you received any

NEW source of income or any ONE-TIME income)

(2)

NO (If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)

(1)

YES

7D. WHAT INCOME CHANGED?

7E. WHEN DID THE INCOME CHANGE?

7F. HOW DID INCOME CHANGE?

(Show what income changed; for example, wages, city

(Show the dates you received any new income or the

(Explain what happened: for example, quit work, got

pension, etc.)

date income changed)

raise, received inheritance)

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)

NOTE: Complete only if you receive Section 306 Pension. Skip to Item 9A if you receive Old Law Pension.

SOURCE

SURVIVING SPOUSE

CASH/NON-INTEREST BEARING BANK ACCOUNTS

INTEREST BEARING BANK ACCOUNTS

IRAs, KEOGH PLANS, ETC.

STOCKS, BONDS, MUTUAL FUNDS, ETC.

REAL PROPERTY (Not your home)

ALL OTHER PROPERTY

8. FAMILY MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)

NOTE: Skip to Item 9A if you receive Old Law Pension.

If Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21-8416,

Medical Expense Report, to report your medical expenses.

9A. SIGNATURE OF CLAIMANT, CUSTODIAN OR GUARDIAN (Read paragraph 6 of the EVR Instructions before signing)

9B. DATE

10. TELEPHONE NUMBERS (Include Area Code)

DAYTIME

EVENING

PENALTY- The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact,

knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.

VA FORM 21-0512s-1, JUN 2004