Va Form 21-0517-1 - Improved Pension Eligibility Verification Report (Veteran With Children)

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OMB Approved No. 2900-0101
Respondent Burden : 40 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN
IMPROVED PENSION ELIGIBILITY
VERIFICATION REPORT
(VETERAN WITH CHILDREN)
7
YOUR COMPLETE MAILING ADDRESS
VA FILE NUMBER
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT Please read the enclosed EVR Instructions (VA Form 21-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER
1B. YOUR SPOUSE’S SOCIAL SECURITY NUMBER
1C. FIRST, MIDDLE, LAST NAME OF SPOUSE
1D. SPOUSE’S DATE OF BIRTH (Mo., day, yr.)
2. MARITAL STATUS (Check only one box)
MARRIED LIVING WITH SPOUSE (You are legally married and you live with your spouse or are separated
(1)
for medical reasons.)
(2)
MARRIED NOT LIVING WITH SPOUSE (You are legally married but separated from your spouse.) Show the
amount you contributed to your spouse’s support during the past 12 months $
If you separated within the last 12 months, show the date of separation
(3)
NOT MARRIED (You have never married or are now divorced or widowed.) If your marriage ended within the
last 12 months, show the date of divorce or death
3A. UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions, VA Form 21-0510)
PLEASE CHECK ONE (X)
FULL NAME OF EACH
DATE OF
SOCIAL SECURITY
OVER 18 AND UNDER
ANY AGE PERMANENTLY
CHILD
BIRTH
UNDER 18
NUMBER
23, AND ATTENDING
HELPLESS FOR MENTAL
(First, middle initial, last)
(Mo., day, yr.)
YEARS OF AGE
SCHOOL
OR PHYSICAL REASONS
3B. UNMARRIED DEPENDENT CHILDREN LISTED IN ITEM 3A WHO DO NOT LIVE WITH YOU
MONTHLY AMOUNT YOU
NAME OF
NAME OF PERSON CHILD
CHILD’S COMPLETE ADDRESS
CONTRIBUTE TO CHILD’S
CHILD
LIVES WITH (If Applicable)
SUPPORT
$
$
$
4C. ENTER THE NAME, COMPLETE ADDRESS,
4A. ARE YOU A PATIENT IN A NURSING HOME?
AND TELEPHONE NUMBER OF NURSING HOME
YES
NO
(If "YES," complete Items 4B through 4D. If "NO," go to Item 5.)
(Please include ZIP Code)
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?
YES
NO
5. DID EITHER YOU OR YOUR SPOUSE RECEIVE WAGES OR WERE EITHER OF 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 ?
(If "YES," write in the VA file number of the other benefit)
YES
NO
21-0517-1
VA FORM
SUPERSEDES VA FORM 21-0517-1, NOV 2002,
(Continued on Reverse)
JUN 2004
WHICH WILL NOT BE USED.

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