Va Form 21-527 - Income, Net Worth, And Employment Statement Page 5
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8PART IV - INFORMATION ABOUT YOUR DISABILITY AND BACKGROUND (Continued)
NOTE: In the table below, tell us about all of your employment, including self-employment, dating from one year before you
became disabled to the present.
25C. WHEN DID
25D. WHEN DID
25E. HOW MANY
25F. WHAT WERE
YOUR WORK
25A. WHAT WAS THE NAME AND
25B. WHAT WAS YOUR
YOUR WORK END?
DAYS WERE MISSED
YOUR TOTAL
BEGIN?
ADDRESS OF YOUR EMPLOYER?
JOB TITLE?
(Mo., day, year)
DUE TO DISABILITY?
ANNUAL EARNINGS?
(Mo., day, year)
$
$
$
$
$
$
26A. CHECK THE HIGHEST YEAR OF EDUCATION YOU COMPLETED:
Grade school:
1
2
3
4
5
6
7
8
9
10
11
12
College:
1
2
3
4
Over 4
26B. LIST THE OTHER TRAINING OR EXPERIENCE YOU HAVE AND ANY CERTIFICATES THAT YOU HOLD:
PART V - NURSING HOME INFORMATION
NOTE: To get your claim processed faster, provide a statement by an official of the nursing home that tells VA that you are a patient in
the nursing home because of a physical or mental disability. Also tell us the amount you pay out-of-pocket for your care.
27B. WHAT IS THE NAME AND COMPLETE MAILING ADDRESS OF THE
27A. ARE YOU NOW IN A NURSING HOME?
FACILITY?
(If "Yes," complete Item 27B)
YES
NO
27C. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME COSTS?
27D. HAVE YOU APPLIED FOR MEDICAID?
(If "No," complete Item 27D)
YES
NO
YES
NO
Page 5
VA FORM 21-527, MAR 2012
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