Va Form 21-0513-1 - Old Law And Section 306 Verification Report (Children Only)
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2OMB Control No. 2900-0101
Respondent Burden: 30 minutes
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN
OLD LAW AND SECTION 306
VETERAN'S SOCIAL SECURITY NUMBER
VERIFICATION REPORT
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(CHILDREN ONLY)
NAME OF CHILD'S CUSTODIAN
VA FILE NUMBER
COMPLETE MAILING ADDRESS OF CHILD OR CUSTODIAN
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 children and
custodians of children 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 2G, Net Worth, and Item 3, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1. CHILD(REN)'S MARITAL AND SCHOOL STATUS
List the children's names, dates of birth, and Social Security numbers, and indicate marital and school status for all children being paid on
this award. If the child does not have a Social Security number, write "No SSN" in the space provided for the child's Social Security
number. If other children are on separate VA awards, they will receive their own EVRs. If additional space is needed, attach a separate
sheet of paper.
NOTE: Complete Item 1E only if the child is 18 years of age or older. Complete Item 1F only if the child is between the ages of 18 and
23 and has not been rated disabled by VA. The child is considered to have attended school continuously if the child attended every
regular school term except summer school or holiday periods. If Block (2), STOPPED SCHOOL, is checked in Item 1E or "NO" is
checked in Item 1F, provide the date the child last attended school in Item 1F.
B. DATE OF
C. SOCIAL
F. ATTENDED SCHOOL
A. FULL NAME OF CHILD
BIRTH
SECURITY
CONTINUOUSLY SINCE
D. MARITAL STATUS
E. SCHOOL STATUS
(First, middle, initial, last)
(Mo., day, yr.)
NUMBER
AGE 18
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
NEVER MARRIED
DISABLED CHILD
NO
(3)
(3)
2. REPORT OF INCOME AND NET WORTH
NOTE: If no income was received from a particular source, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
(Read Paragraphs 2 and 3 of the EVR Instructions)
A. MONTHLY INCOME
CHILD'S NAME:
CHILD'S NAME:
CHILD'S NAME:
SOURCE
$
$
$
SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY
INCOME (SSI)
(Show source)
OTHER INCOME
(Show source)
OTHER INCOME
VA FORM
21-0513-1
SUPERSEDES VA FORM 21-0513-1, JUN 2001,
(Continued on Reverse)
JUN 2004
WHICH WILL NOT BE USED.
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