Va Form 21-4185 - Report Of Income From Property Or Business

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OMB Control No. 2900-0108
Respondent Burden: 30 Mins.
REPORT OF INCOME FROM PROPERTY OR BUSINESS
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. 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 to determine eligibility for benefits (38 U.S.C. 1315 and 1506). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 30 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.
INSTRUCTIONS: Please provide specific information about the gross income and expenses of your property and/or business, so we can determine eligibility for
benefits. Print all answers clearly. If an answer is "none" or "0," write that or line through the space provided. For additional space, attach a separate sheet, indicating
the item number to which the answers apply. Make sure to write the veteran's name and VA claim number on any attachments to the form.
Rental income: Net rental income is gross rental income less expenses. Depreciation and payments on the principal of a mortgage are not deductible. If the rental
property is partially occupied by the owner, report the gross income received and the proportionate part of the expenses. For example: If you own a two-family
house that is occupied by you and another family, report the gross income you receive from the other family and one-half of the expenses.
Business income: Net business income is gross income less operating expenses. Depreciation, withdrawals of cash or merchandise, and salaries paid you or your
partners are not deductible. Deductible operating expenses include cost of goods sold, rent, normal repairs, taxes (other than Federal income tax), salary or wages of
employees, insurance, interest on business debts, and similar expenses.
1. FIRST NAME-MIDDLE NAME-LAST NAME OF VETERAN
2. VA FILE NUMBER
3. FIRST NAME-MIDDLE NAME-LAST NAME OF CLAIMANT (If other than veteran)
4. MAILING ADDRESS OF CLAIMANT (Number and street or rural route or P.O. Box, city, State and ZIP Code)
5. WHAT PORTION OF RENTAL
PROPERTY, IF ANY, IS OCCUPIED
BY CLAIMANT?
6. ADDRESS OF RENTAL PROPERTY
7. BRIEF DESCRIPTION OF RENTAL PROPERTY (Include number and type
of units)
8. ADDRESS OF BUSINESS
9. TYPE OR NATURE OF BUSINESS
10A. VALUE AT BEGINNING OF CURRENT CALENDAR
10B. VALUE AT END OF CURRENT CALENDAR YEAR
STOCK INVENTORY
YEAR
OF BUSINESS
$
$
(11B)
(11C)
(11A)
EXPENSES FOR THE PERIOD
EXPENSES FOR THE PERIOD
TOTAL EXPENSES RELATING TO RENTAL PROPERTY OR
FROM
THRU
FROM
THRU
LINE
NO.
OPERATION OF BUSINESS
NOTE: Do not list personal expenditures.
(If no dates are shown, report
(If no dates are shown, report
expenses for current calendar year)
expenses for last calendar year)
1
TAXES
$
$
2
UTILITIES (If furnished)
3
INSURANCE
4
INTEREST ON MORTGAGE
5
FUEL (If furnished)
6
NORMAL REPAIRS
7
COST OF GOODS SOLD
8
RENT
9
EMPLOYEES' SALARIES
21-4185
EXISTING STOCKS OF VA FORM 21-4185, MAR 2005,
Continued on reverse
VA FORM
WILL BE USED.
DEC 2011

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