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Get Va Form 21p 0969

SUPERSEDES VA FORM 21-0518-1 JUN 2004 WHICH WILL NOT BE USED. Continued on Next Page 7A. MONTHLY INCOME Read Paragraphs 2 and 3 of the EVR Instructions If no income or net worth was received from a particular source write 0 or none. DID YOU RECEIVE ANY WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS 6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN PARENT OR SURVIVING SPOUSE VA FORM FEB 2012 21-0518-1 If Yes write in the VA file number of the other benefit. SIGNATURE OF PAYEE Read paragraph 9 of the EVR Instructions before signing 10B. DATE SIGNED 10C. TELEPHONE NUMBERS Include Area Code DAYTIME EVENING PENALTY The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of a material fact knowing it is false or fraudulent acceptance of any payment to which you are not entitled. VA FORM 21-0518-1 FEB 2012. OMB Control No. 2900-0101 Respondent Burden 30 minutes FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN IMPROVED PENSION ELIGIBILITY VERIFICATION REPORT SURVIVING SPOUSE WITH NO CHILDREN 8 COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE VA FILE NUMBER VA REGIONAL OFFICE RETURN ADDRESS IMPORTANT - Please read the enclosed EVR Instructions VA Form 21-0510 prior to completing this form. 1B. VETERAN S SOCIAL SECURITY NUMBER 1A. YOUR SOCIAL SECURITY NUMBER 1C. YOUR DATE OF BIRTH Mo. day yr. 2. YOUR MARITAL STATUS Check only one box I HAVE NOT REMARRIED SINCE THE VETERAN DIED You have not married anyone since the veteran s death. If you are using this form as your annual Eligibility Verification Report and Paragraph 6 of the EVR Instructions indicates that you should report medical expenses use VA Form 21-8416 Medical Expense Report to report your medical expenses. If you are using this form as a supplement to a pending claim you do not need to report medical expenses. STOCKS BONDS MUTUAL FUNDS ETC. REAL PROPERTY Not your home ALL OTHER PROPERTY 8. FAMILY MEDICAL EXPENSES Read Paragraph 6 of the EVR Instructions Normally medical expenses are reported at the end of the year. If you are using this form as your annual Eligibility Verification Report and Paragraph 6 of the EVR Instructions indicates that you should report medical expenses use VA Form 21-8416 Medical Expense Report to report your medical expenses. If you are using this form as a supplement to a pending claim you do not need to report medical expenses. If entitlement is established you will have an opportunity to report your medical expenses at the end of the year. of the EVR Instructions. Show amounts paid by you during the past 12 months. DO NOT REPORT CHILDREN S EXPENSES. 10A. VETERAN S SOCIAL SECURITY NUMBER 1A. YOUR SOCIAL SECURITY NUMBER 1C. YOUR DATE OF BIRTH Mo. day yr. 2. YOUR MARITAL STATUS Check only one box I HAVE NOT REMARRIED SINCE THE VETERAN DIED You have not married anyone since the veteran s death. I REMARRIED ON Date AND I AM STILL MARRIED You married after the veteran s death and you are currently married* Enter the date you married your current spouse.

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