Va Form 21-0512v-1 - Old Law And Section 306 Eligibility Verification Report (Veteran)
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2OMB Approved No. 2900-0101
Respondent Burden: 30 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN
OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
2V
(VETERAN)
YOUR COMPLETE MAILING ADDRESS
VA FILE NUMBER
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21-0510) before completing this form. This form is used by veterans receiving
Old Law or Section 306 Pension. If you have been receiving a fixed rate of pension since 1960, you receive Old Law Pension. If you have been
receiving a fixed rate of pension since 1978 you receive Section 306 Pension. If you receive Old Law Pension, do not complete Item 7G, Net Worth,
and Item 8, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1A. YOUR SOCIAL SECURITY NUMBER
1B. YOUR SPOUSES'S SOCIAL SECURITY NUMBER
(Mo., day, yr.)
1C. FIRST NAME - MIDDLE NAME - LAST NAME OF YOUR SPOUSE
1D. YOUR SPOUSE'S DATE OF BIRTH
(Check one box)
2. MARITAL STATUS
(You are legally married and live with your spouse or you live apart only for medical reasons.)
(1)
MARRIED-LIVING WITH SPOUSE
(You are legally married but estranged from your spouse.)
(2)
MARRIED-NOT LIVING WITH SPOUSE
Show the amount you contributed to your spouse's support during the last 12 months $
If you separated within the last 12 months, show the date of separation
(You have never married or are now divorced or widowed.)
(3)
NOT MARRIED
If your marriage ended within the last 12 months, show the date of divorce or death
3A. NUMBER OF UNMARRIED DEPENDENT CHILDREN
3B. AMOUNT CONTRIBUTED DURING PAST 12
(See Paragraph 1 of the EVR Instructions)
MONTHS TO CHILDREN NOT IN YOUR CUSTODY
IN YOUR CUSTODY
NOT IN YOUR CUSTODY
$
(If "YES," Complete Items 4B thru 4D. If "NO," go to Item 5.)
4A. ARE YOU A PATIENT IN A NURSING HOME?
YES
NO
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
4C. ENTER THE NAME, COMPLETE ADDRESS, AND TELEPHONE
(Please include ZIP Code)
NUMBER OF THE NURSING HOME
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?
YES
NO
5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
YES
NO
(If you checked "YES," write in the VA File number of the other benefit)
VA FORM
SUPERSEDES VA FORMS 21-0511V-1, NOV 1996 AND
(Continued on Reverse)
21-0512V-1
JUN 2004
21-0512V-1, MAY 2003, WHICH WILL NOT BE USED.
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