Va Form 21-535 - Application For Dependency And Indemnity Compensation By Parent(S) Page 6
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1029. Are you claiming the aid and attendance
30a. Are you now in a nursing home?
SECTION
Tell us if you
allowance because you need the regular
VI
are in a
assistance of another person or have severe
nursing home
visual problems?
or require aid
and
Yes
No
Yes
No
attendance
(If "No," skip to Section VII.)
(If "YES," answer Items 30b also.)
If you answered "yes" to item
29 and are not in a nursing
30b. What is the name and complete mailing address of the facility?
home, submit a statement from
your doctor showing the extent
of your disabilities. If you are
in a nursing home, attach a
statement signed by an official
of the nursing home showing
the date you were admitted to
the nursing home, the level of
care you receive, and the
amount you pay-out-of-pocket
for your care.
Report the total amounts before you take out deductions for taxes, insurance, etc.
SECTION
Tell us about
Do not report the same income in both tables.
VII
the income of
If you expect to receive a payment, but you don't know how much it will be, write "Unknown" in
you and your
the space.
spouse
If you do not receive any payments from one of the sources that we list, write "0" or "None" in the
space.
Payments from any source will
VA will interpret a blank space to mean "0" or "None".
be counted, unless the law
indicates that they don't need to
If you are receiving monthly benefits, give us a copy of your most recent award letter. This will
be counted. Report all income
help us determine the amount of benefits you should be paid.
in the tables below, and VA
31. Have you claimed or are you receiving
32. Have you filed a claim for compensation
will determine any amount that
benefits from the Social Security
from the Office of Worker's Compensation
does not count.
Administration?
Programs based on the death of the veteran?
Yes
No
Yes
No
33. Has a court awarded damages based on the
death of the veteran or is a claim or legal
action for damages pending?
Yes
No
Monthly Income-Tell us the income you and your spouse receive every month
Note: If you are filing this application as the guardian or custodian of the veteran's parent, do not report your own income.
Spouse
Sources of recurring monthly income
Parent
(if living together)
34a. Social Security
$
$
34b. U.S. Civil Service
34c. U.S. Railroad Retirement
34d. Military Retirement
34e. Black Lung Benefits
34f. Other income received monthly (Please write source below)
34g. Other income received monthly (Please write source below)
VA FORM 21-535, FEB 2012
21-535
page 4
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