Fillable Va Form 21-8941 - Reps Annual Eligibility Report printable pdf download

OMB Approved No. 2900-0405

Respondent Burden: 15 minutes

REPS ANNUAL ELIGIBILITY REPORT

(Under the Provisions of Section 156, Public Law 97-377)

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of

1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., 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) as 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. Your obligation to respond is required to obtain

or retain benefits. Giving us your SSN account information is voluntary. Providing your SSN will help ensure that your records are properly associated with your claim

file. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN

unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered

relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted

is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information in order to determine continued eligibility for REPS benefits (38 U.S.C. 5101 (a)). Title 38, United States Code,

allows us to ask for this information. We estimate that you will need an average of 15 minutes 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.

(First, middle, last)

1A. NAME OF CLAIMANT

1B. CLAIMANT'S SOCIAL SECURITY

1C. VETERAN'S/WAGE EARNER'S

NUMBER

SOCIAL SECURITY NUMBER

2A. GROSS EARNINGS LAST YEAR

2B. ANTICIPATED GROSS EARNINGS THIS YEAR

4B. NUMBER OF HOURS WORKED

3A. WERE YOU SELF-EMPLOYED

3B. NUMBER OF HOURS WORKED

4A. ARE YOU CURRENTLY SELF-

PER WEEK

EMPLOYED?

YES

(If "Yes," complete Item 4B)

(If "Yes," complete Item 3B)

5. EMPLOYMENT HISTORY

A. DID YOU BEGIN WORKING

B. DATE YOU BEGAN WORKING

C. DID YOU QUIT WORKING

D. DATE YOU QUIT WORKING

LAST YEAR?

YES

(If "Yes," complete Item 5B)

(If "Yes," complete Item 5D)

E. ARE YOU CURRENTLY EMPLOYED?

F. NAME AND ADDRESS OF YOUR EMPLOYER(S)

G. DO YOU ANTICIPATE

BEGINNING EMPLOYMENT THIS

YEAR?

YES

6. MARITAL STATUS

A. DID YOU REMARRY LAST YEAR OR

B. DATE OF MARRIAGE

C. COMPLETE MARRIED NAME

THIS YEAR TO DATE?

YES

7. STATUS OF YOUNGEST DEPENDENT CHILD IN YOUR CARE WHILE AGE 16 TO 18

A. NAME OF CHILD OF THE VETERAN IN YOUR CARE BETWEEN THE AGES OF 16 AND 18 YEARS OLD

B. HAS THIS DEPENDENT MARRIED OR

OTHERWISE LEFT YOUR CARE?

YES

(If "Yes," complete Items 7C - 7E)

(If necessary use Item 8)

C. DATE OF MARRIAGE

D. DATE CHILD LEFT YOUR CARE

E. EXPLAIN WHY CHILD IS NO LONGER IN YOUR CARE

8. REMARKS

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,

knowing it to be false.

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

9B. DATE

9A. SIGNATURE OF CLAIMANT OR GUARDIAN

(Including Area Code)

9C. TELEPHONE NO(S)

DAYTIME

EVENING

EXISTING STOCKS OF VA FORM 21-8941, OCT 2004,

VA FORM

21-8941

WILL BE USED.