Verification Of Veterans Administration Benefits
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1VERIFICATION OF VETERANS ADMINISTRATION BENEFITS
(Name of HOME Participating Jurisdiction)
Name of Veteran: ________________________
Address:
Claim No.: _____________________________
AUTHORIZATION: Federal Regulations
Date of Birth: ___________________________
require us to verify Veterans Administration
Benefits Income of all members of the
Service Dates: ___________ to ____________
household applying for participation in the
HOME Program which we operate and to
Benefits Paid to: ________________________
reexamine this income periodically. We ask
your cooperation in supplying this
1. Current Benefit Amount
$__________
information. This information will be used
2. Original Start Date
__________
only to determine the eligibility status and
3. This amount will increase/
level of benefit of the household.
decrease to (circle one)
$__________
Date Change Takes Effect
__________
Your prompt return of the requested
information will be appreciated. A self-
4. Benefits are for:
addressed return envelope is enclosed.
_
GI Bill Training
_
Insurance
_
Service Connected Compensation
Disability (%) _____________
_
Nonservice Pension Death
_
Service Connected Compensation Death
_
Other
________________________________
________________________________
RELEASE: I hereby authorize the release
Signature of _____________________________
of the requested information.
or Authorized Representative
___________________________________
_______________________________________
(Signature of Applicant)
Title: ___________________________________
Date: ______________________________
Or a copy of the executed “HOME Program
Date: __________________________________
Eligibility Release Form,” which authorizes
the release of the information requested, is
attached.
Telephone: _____________________________
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for
knowingly and willingly making false or fraudulent statements to any department of the
United States Government.
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