Va Form 21-526 - Part D - Veterans Application For Compensation And/or Pension Page 2

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SECTION
Tell us
II
your
In the table below, tell us about all of your employment, including
II
work
self-employment, for one year before you became disabled to the present.
history
5a. What was the name and
5b. What was your
5c. When did
5d. When did
5e. How many
5f. What were your
address of your employer?
job title?
your work
your work
days were
total annual
begin?
end?
lost due to
earnings?
disability?
$
.
mo day yr
mo day yr
$
.
mo day yr
mo day yr
$
.
mo day yr
mo day yr
Tell us
SECTION
if you
III
In this section, tell us if you are in a nursing home. If you are in a nursing home, give us
are in a
more information about the nursing home.
nursing
home
To get your claim
6b. What is the name and complete
6a. Are you now in a nursing home?
processed faster,
mailing address of the facility or
provide a statement
doctor?
by an official of the
Yes
No
nursing home that
tells us that you are
(If "yes," answer Item 6b also)
a patient in the
nursing home
because of a
physical or mental
disability and tells
us the daily charge
6c. Does Medicaid cover all or part of
6d. Have you applied for Medicaid?
for your care.
your nursing home costs?
Yes
No
Yes
No
(If "no," answer Item 6d also)
In this section, we ask you to give us specific information about your net worth and the net worth
Tell us the
SECTION
of your dependents. You will need to enter this information in the tables on page 3.
net worth
IV
of you and
You must include all assets in your net worth except those items you use everyday (See
definition of net worth below.)
your
You should subtract from the market value of your real estate any amounts that you owe
dependents
on it (such as mortgages, liens, etc.)
You can subtract mortgages on any property, and the value of the house or part of a
building that you live in as your primary residence.
You can report farms or buildings that you or a dependent own by reporting its value as
"real property."
Definitions:
VA cannot pay you
Net worth is the market value of all interest and rights in any kind of property less any mortgages
pension if your net
or other claims against the property. However, net worth does not include the house you live in or
worth is sizeable.
a reasonable area of land it sits on. Net worth also does not include the value of personal things
you use everyday like your vehicle, clothing, and furniture.
Go to Page 3 and fill out the table.
21-526, Part D
Page 2

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