Va Form 21-527 - Income, Net Worth, And Employment Statement Page 7

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PART VIlI - INFORMATION ABOUT YOU AND YOUR DEPENDENTS EXPECTED ANNUAL INCOME (Continued)

EXPECTED INCOME FOR THE NEXT 12 MONTHS - TELL US ABOUT OTHER INCOME YOU AND YOUR DEPENDENTS RECEIVE

CHILD(REN)

Name

SOURCE OF INCOME FOR THE

(First, middle, last)

VETERAN

SPOUSE

NEXT 12 MONTHS

32A. Total interest and dividends

32B. Worker's compensation or

unemployment compensation

32C. Other income expected

(Please write source below)

PART IX - INFORMATION ABOUT YOUR MEDICAL, LEGAL OR OTHER UNREIMBURSED EXPENSES

NOTE: Family medical expenses and certain other expenses you actually paid may be deductible from your income. Show the amount of

unreimbursed medical expenses, including the Medicare deduction, you paid over the last year for yourself or relatives who are members of

your household. Also, show unreimbursed last illness and burial expenses and educational or vocational rehabilitation expenses you paid. Last

illness and burial expenses are unreimbursed amounts you paid for the last illness and burial of a spouse or child at any time prior to the end of

the year following the year of death. Educational or vocational rehabilitation expenses are amounts you paid for courses of education including

tuition, fees, and materials. Show medical, legal or other expenses you paid because of a disability for which you were awarded civilian

disability benefits. When determining your income we may be able to deduct them from the disability benefits for the year in which the expenses

are paid. Do not include any expenses for which you were reimbursed. If more space is needed, attach a separate sheet.

33D. PAID TO

33E. DISABILITY OR

33B. DATE PAID

33C. PURPOSE (Doctor's fees, hospital

33A. AMOUNT YOU

RELATIONSHIP OF

(Name of doctor, hospital,

(Month, day, year)

charges, attorney fees, etc.)

PERSON FOR WHOM

PAID

pharmacy, etc.)

EXPENSES PAID

PART X - DIRECT DEPOSIT INFORMATION

If benefits are awarded we will need more information in order to process any payments to you. Please read the paragraph below

and then either:

1. Attach a voided check, or

2. Answer Items 34-36.

The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. Please attach a

voided personal check or deposit slip or provide the information requested in Items 34, 35 and 36 to enroll in direct deposit. If you do not have a bank

account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard you must apply at

or by telephone at 1-800-333-1795. If you elect not to enroll, you must contact representatives handling waiver requests for the

Department of Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any questions or concerns you may have.

34. ACCOUNT NUMBER - PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE THE ACCOUNT NUMBER, IF APPLICABLE

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR A

CHECKING

SAVINGS

CERTIFIED PAYMENT AGENT

ACCOUNT NUMBER

35. NAME OF FINANCIAL INSTITUTION

36. ROUTING OR TRANSIT NUMBER

VA FORM 21-527, MAR 2012