Sweet Frog Hiring Form – Fill Out and Use This PDF

IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.

1C. YOUR DATE OF BIRTH (Mo., day, yr.)

2.YOUR MARITAL STATUS (Check only one box)

(1) I HAVE NOT REMARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran's death.)

3. NUMBER OF UNMARRIED, DEPENDENT CHILDREN (See Paragraph 1 of the EVR Instructions)

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME FEES?

YES NO

5.DID YOU RECEIVE ANY WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS?

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". VA WILL INTERPRET A BLANK SPACE AS "NONE" OR "0."

7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)

If no income was received from a particular source, write "0" or "none". VA WILL INTERPRET A BLANK SPACE AS "NONE" OR "0."

NOTE: Report annual income for the dates indicated. If no dates are shown above the columns that follow, then report last calendar year (January through December) income in the left-hand column and current calendar year income in the right-hand column.

7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING PAST 12 MONTHS? (Answer "NO" if there were no income changes or if the only change was a Social Security/VA cost-of-living adjustment. Answer "YES" if there were any other income changes or if you received any NEW source of income or any ONE-TIME income)

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 21P-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.

10C. TELEPHONE NUMBERS (Include Area Code)

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.