Va Form 21-527 - Income, Net Worth, And Employment Statement Page 2
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8GENERAL INSTRUCTIONS (Continued)
What do I do when I have completed my application?
When you have completed this application, mail it or take it to a VA regional office. You can locate the mailing address of
your nearest VA regional office at Be sure to attach any materials that support and explain your claim.
Also, for your records, make a photocopy of your application and everything that you submit to VA before you mail it.
How can I assign someone to act as my representative?
An accredited representative of a veteran's organization or other service organization recognized by the Secretary of
Veterans Affairs may represent you without charge. An accredited attorney or agent may also represent you. However under
38 U.S.C. 5904(c), an accredited agent or attorney may only charge you for services performed after the date you file a
Notice of Disagreement.
If you want to use a representative to help you with your application, contact the nearest VA office. Depending on the type of
representative you want to designate, we will send you one of the following forms:
•
VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative or
•
VA Form 21-22A, Appointment of Individual as Claimant's Representative
You may download these forms at: If you have already designated a representative, no further action
is required on your part.
Net Worth
VA considers all of your (and your spouse's) assets ("net worth") in determining your eligibility for non service-connected
pension. Transferring your cash or property to another person, trust, organization, corporation or any other entity does not
reduce your net worth in order to qualify for pension unless it is clear that you have permanently given up all rights of
ownership, including the right to control the cash or property. In completing this form, you must tell us about all assets you
have transferred in the last two (2) years, along with any assets you transferred previously for any period of time if the value
of the asset(s) exceeded a total of $20,000. In section VII, Items 29A and 29B, report all transferred assets. Note the
conditions of transfer in Item 37, "Remarks," including any remaining right, privilege of ownership, benefit, or control you
have over the asset.
PRIVACY ACT INFORMATION: The form will be used to determine allowance to pension benefits (38 U.S.C. 5101). The
responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you provide,
including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act, including the routine
uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. The requested information is considered
relevant and necessary to determine maximum benefits under the law. Information submitted is subject to verification
through computer matching programs with other agencies. VA may make a "routine use" disclosure for: civil or criminal law
enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and
delivery of VA benefits, verification of identity and status, and personnel administration. Your obligation to respond is
required in order to obtain or retain benefits. Information that you furnish may be utilized in computer matching programs
with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect
any amount owed to the United States by virtue of your participation in any benefit program administered by the Department
of Veterans Affairs. Social Security information: You are required to provide the Social Security number requested under 38
U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may
disclose them for purposes stated above.
RESPONDENT BURDEN: We need this information to determine your eligibility for pension. Title 38, United States Code,
allows us to ask for this information. We estimate that you will need an average of 1 hour to review the instructions, find the
information, and complete this form. VA cannot conduct or sponsor a collection of information, unless a valid OMB Control
Number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid
OMB control numbers can be located on the OMB Internet Page at If desired, you can
call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21-527, MAR 2012
Page 2
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