Va Form 21-4103 - Information From Remarried Widow/er Page 3
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3PART IV - ANNUAL INCOME
NOTE: If you have no income or net worth from a particular source, write "0" or "none." Do not leave any items blank.
AMOUNTS
NAME OF CHILD/REN
ITEM
SOURCE
SPOUSE
NO.
WIDOW/ER
(Income from date
of marriage)
AMOUNT RECEIVED FROM JANUARY 1 TO DATE WIDOW/ER REMARRIED
10A.
EARNINGS
10B
SOCIAL SECURITY
10C.
OTHER ANNUITIES AND RETIREMENTS
10D.
DIVIDENDS, INTEREST, ETC.
Specify source)
10E.
OTHER INCOME (
(Specify source)
10F.
OTHER INCOME
AMOUNT EXPECTED FROM DATE WIDOW/ER REMARRIED THROUGH END OF CALENDAR YEAR
11A.
EARNINGS
11B.
SOCIAL SECURITY
11C.
OTHER ANNUITIES AND RETIREMENTS
11D.
DIVIDENDS, INTEREST, ETC.
(Specify source)
11E.
OTHER INCOME
11F.
(Specify source)
OTHER INCOME
AMOUNT EXPECTED NEXT CALENDER YEAR
12A.
EARNINGS
12B.
SOCIAL SECURITY
12C.
OTHER ANNUITIES AND RETIREMENTS
12D.
DIVIDENDS, INTEREST, ETC.
Specify source)
12E.
OTHER INCOME (
(Specify source)
12F.
OTHER INCOME
(Use this space for any additional information regarding this claim)
13. REMARKS
CERTIFICATION: I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
14. SIGNATURE
15. DATE SIGNED
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 to be false, or fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-4103, JUN 2011
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