Va Form 21p-0519c-1 - Improved Pension Eligibility Verification Report (Child Or Children)
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2OMB Approved No. 2900-0101
Respondent Burden : 30 minutes
Expiration Date: 04/30/2018
FIRST, MIDDLE, LAST NAME OF VETERAN
IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(CHILD OR CHILDREN)
9C
VETERAN'S SOCIAL SECURITY NUMBER
VA FILE NUMBER
COMPLETE MAILING ADDRESS OF CHILD OR CUSTODIAN
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT -Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.
1. CHILD(REN)'S MARITAL AND SCHOOL STATUS
List the children's names, dates of birth, and Social Security numbers, and indicate marital and school status for all children being paid
on this award. If the child does not have a Social Security number, write "No SSN" in the space provided for the child's Social
Security number. If other children are on separate VA awards, they will receive their own EVRs. If additional space is needed, attach a
separate sheet of paper.
NOTE: Complete Item 1E only if the child is 18 years of age or older. Complete Item 1F only if the child is between the ages of 18
and 23 and has not been rated disabled by VA. The child is considered to have attended school continuously if the child attended every
regular school term except summer school or holiday periods. If Block (2), STOPPED SCHOOL, is checked in Item 1E or "NO" is
checked in Item 1F, provide the date the child last attended school in Item 1F.
A. FULL NAME OF EACH
B. DATE OF
F. ATTENDED SCHOOL
C. SOCIAL SECURITY
CHILD
BIRTH
D. MARITAL STATUS
E. SCHOOL STATUS
CONTINUOUSLY
NUMBER
(First, middle initial, last)
(Mo.,day,yr.)
SINCE AGE 18
DATE LEFT
(1)
MARRIED
(1)
ATTENDS SCHOOL
SCHOOL
(2)
DIVORCED/WIDOWED
(2)
(1)
YES
STOPPED SCHOOL
NEVER MARRIED
(3)
DISABLED CHILD
NO
(3)
(2)
(1)
MARRIED
(1)
ATTENDS SCHOOL
YES
(2)
DIVORCED/WIDOWED
(2)
STOPPED SCHOOL
(1)
NEVER MARRIED
DISABLED CHILD
NO
(3)
(3)
(2)
ATTENDS SCHOOL
(1)
MARRIED
(1)
YES
DIVORCED/WIDOWED
STOPPED SCHOOL
(2)
(2)
(1)
(3)
NEVER MARRIED
(3)
DISABLED CHILD
NO
(2)
MARRIED
(1)
(1)
ATTENDS SCHOOL
YES
(2)
STOPPED SCHOOL
(2)
DIVORCED/WIDOWED
(1)
DISABLED CHILD
NO
NEVER MARRIED
(3)
(3)
(2)
MARRIED
ATTENDS SCHOOL
(1)
(1)
YES
DIVORCED/WIDOWED
STOPPED SCHOOL
(2)
(2)
(1)
(3)
NEVER MARRIED
(3)
DISABLED CHILD
NO
(2)
(1)
MARRIED
(1)
ATTENDS SCHOOL
YES
DIVORCED/WIDOWED
STOPPED SCHOOL
(2)
(2)
(1)
NEVER MARRIED
DISABLED CHILD
NO
(3)
(3)
(2)
2. DID ANY CHILD ON THIS AWARD RECEIVE WAGES AT ANY TIME DURING THE LAST 12 MONTHS?
YES
NO
Page 1
VA FORM
SUPERSEDES VA FORM 21-0519C-1, APR 2012,
21P-0519C-1
APR 2015
WHICH WILL NOT BE USED.
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