Va Form 21-526 - Part D - Veterans Application For Compensation And/or Pension (Page 4 of 4) in pdf

Va Form 21-526 - Part D - Veterans Application For Compensation And/or Pension Page 4

Monthly Income Tell us the income you and your dependents receive

SECTION V (Continued)

every month.

For Items 11a-12f if none write "0" or "None"

Child(ren)

Sources of recurring

I. Name:

II. Name:

III. Name:

Veteran

Spouse

monthly income

(first, middle initial, last)

11a. Social Security

11b. U.S. Civil Service

11c. U.S. Railroad

Retirement

11d. Military Retired Pay

11e. Black Lung Benefits

11f. Supplemental Security

(SSI)/Public Assistance)

11g. Other income

received monthly

(Please write in the

source below:)

Next 12 months

Tell us about other income for you and your dependents

Child(ren)

Sources of income

I. Name:

II. Name:

III. Name:

for the next 12

Veteran

Spouse

months

(first, middle initial, last)

12a. Gross wages

and salary

12b. Total interest

and dividends

12c. Worker’s

compensation for

injury

12d. Unemployment

compensation

12e. Other military

benefit (Please write

in the source below:)

12f. Other one-time

benefit (Please write

in the source below:)

Tell us any information concerning, Medical, Legal or Other Expenses

Family medical expenses actually paid by you may be

SECTION VI

deductible from your income. Show the amount of unreimbursed medical expenses you paid for yourself or relatives you are under an

obligation to support. Also, show medical, legal or other expenses you paid because of a disability for which civilian disability benefits have

been awarded. When determining your income, we may be able to deduct them from the disability benefits for the year in which the

expenses are paid. Do not include any expenses for which you were reimbursed. Show the Medicare deduction in line 1. If more space is

IMPORTANT Items 13A

needed attach a separate sheet.

through 13E should be

13E. DISABILITY OR

13C. PURPOSE

completed only if you are

13D. PAID TO

13A. AMOUNT PAID

13B. DATE

RELATIONSHIP OF PERSON

(Doctor’s fees, hospital

(Name of doctor, hospital,

applying for

BY YOU

PAID

FOR WHOM EXPENSES PAID

charges, Attorney fees,etc)

pharmacy, Attorney, etc.)

nonservice-connected

pension.

Your Social Security Number

Your name

21-526, Part D

Page 4

Va Form 21-526 - Part D - Veterans Application For Compensation And/or Pension Page 4

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