Va Form 21-527 - Income, Net Worth, And Employment Statement Page 3
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8OMB Approved No. 2900-0002
Respondent Burden: 1 Hour
INCOME, NET WORTH, AND EMPLOYMENT STATEMENT
(DO NOT WRITE IN THIS SPACE)
IMPORTANT - Read Privacy Act and Respondent Burden Information and Instructions carefully before
(VA DATE STAMP)
completing the form. Type, print, or write plainly.
PART I - VETERAN/CLAIMANT INFORMATION
(Type or Print)
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN/CLAIMANT
2A. VETERAN/CLAIMANT SOCIAL SECURITY NO.
2B. VA FILE NO.
(Number, street or rural route, City or P.O., State and ZIP Code)
3. ADDRESS OF VETERAN/CLAIMANT
(Include Area Code)
4A. TELEPHONE NUMBER(S)
(If applicable)
4B. E-MAIL ADDRESS
DAYTIME
EVENING
CELL
PART II - MARITAL INFORMATION
NOTE: If married, you should provide a copy of your marriage certificate.
5. WHAT IS YOUR MARITAL STATUS?
(If you are divorced or widowed skip to Item 14)
(If never married skip to Part III)
DIVORCED
NEVER MARRIED
MARRIED
WIDOWED
(Month, day, year)
(City, State or Country)
6A. WHEN WERE YOU MARRIED?
6B. WHERE DID YOU GET MARRIED?
(First, middle, last)
(Month, day, year)
9. SPOUSE'S SOCIAL SECURITY NO.
7. SPOUSE'S NAME
8. SPOUSE'S BIRTHDAY
(If any)
10A. IS YOUR SPOUSE ALSO A VETERAN?
10B. SPOUSE'S VA FILE NO.
11. DO YOU LIVE WITH YOUR SPOUSE?
(If "Yes," skip to Item
14) (If "No," complete
(If "Yes," complete Item 10B, if known)
YES
NO
YES
NO
Items 12, 13A & 13B)
(Number and street or rural route, city or P.O., State
12. SPOUSE'S ADDRESS
13A. IF YOU DO NOT LIVE WITH YOUR
13B. HOW MUCH DO YOU
SPOUSE PLEASE PROVIDE THE REASON
CONTRIBUTE MONTHLY
and ZIP Code)
(i.e., illness, work, etc.)
TO SPOUSE'S SUPPORT?
$
INFORMATION ABOUT THE VETERAN'S & SPOUSE'S PREVIOUS MARRIAGES
NOTE: Furnish the following information about all of your and your present spouse's previous marriages. If you need additional space please
attach a separate sheet of paper providing the requested information about the marriages.
14. HOW MANY TIMES HAVE YOU BEEN MARRIED?
15F. REASON
15A. DATE OF
15B. PLACE OF
15D. DATE
15E. PLACE
15C. NAME OF FORMER SPOUSE
MARRIAGE
MARRIAGE
MARRIAGE
MARRIAGE ENDED
MARRIAGE ENDED
(First, Middle, Last)
ENDED
(Month, Day, Year)
(City, State or Country)
(Month, Day, Year)
(City, State or Country)
(Death, Divorce)
16. HOW MANY TIMES HAS YOUR CURRENT SPOUSE BEEN MARRIED?
17F. REASON
17A. DATE OF
17B. PLACE OF
17D. DATE
17E. PLACE
17C. NAME OF FORMER SPOUSE
MARRIAGE
MARRIAGE
MARRIAGE
MARRIAGE ENDED
MARRIAGE ENDED
(First, Middle, Last)
ENDED
(Month, Day, Year)
(City, State or Country)
(Month, Day, Year)
(City, State or Country)
(Death, Divorce)
VA FORM
SUPERSEDES VA FORM 21-527, JUN 2004, WHICH
Page 3
21-527
MAR 2012
WILL NOT BE USED.
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