Va Form 21 0517 1 PDF Details

The VA 21 0517 1 form, known as the Improved Pension Eligibility Verification Report (Veteran with Children), serves as a critical tool in the administration of benefits for veterans with dependents, ensuring that those who have served the country and their families receive the support they are entitled to. With a respondent burden of 40 minutes and an expiration date of 06/30/2021, this document requires detailed information from veterans, including personal identification, marital status, details about children, potential nursing home residency, employment status over the previous year, other VA benefits received, income, net worth, and medical expenses, among other crucial data. Designed to comprehensively assess a veteran's financial situation and the eligibility for improved pensions, the form plays a vital role in maintaining transparency and accuracy in benefit distribution. Additionally, the form includes important notes on legal aspects related to claims processing, such as the fees that may be charged by VA-accredited attorneys or agents under Section 5904, Title 38, U.S. Code. The overall purpose of this document underscores the dedication to supporting veterans and their families through meticulously structured benefit programs, ensuring that assistance is tailored to individual circumstances and needs.

QuestionAnswer
Form NameVa Form 21 0517 1
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names21 0516, 21p 0516 1, 21 0516 1, va form 21p 0516 1

Form Preview Example

OMB Control No. 2900-0101

Respondent Burden: 40 minutes

Expiration Date: 06/30/2021

FIRST, MIDDLE, LAST NAME OF VETERAN

 

IMPROVED PENSION ELIGIBILITY

 

 

VERIFICATION REPORT

 

 

(VETERAN WITH CHILDREN)

7

 

 

 

 

 

YOUR COMPLETE MAILING ADDRESS

VA FILE NUMBER

 

 

 

 

 

VA REGIONAL OFFICE RETURN ADDRESS

 

FEES FOR CLAIMS - Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of- attorney and the fee agreement requirements.

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

1A. YOUR SOCIAL SECURITY NUMBER

1B. YOUR SPOUSE'S SOCIAL SECURITY NUMBER

1C. FIRST, MIDDLE, LAST NAME OF SPOUSE

1D. SPOUSE'S DATE OF BIRTH (Mo., day, yr.)

2.MARITAL STATUS (Check only one box)

(1) MARRIED-LIVING WITH SPOUSE (You are legally married and you live with your spouse or are separated for medical reasons.)

(2) MARRIED-NOT LIVING WITH SPOUSE (You are legally married but separated from your spouse.) Show the amount

you contributed to your spouse's support during the past 12 months $ If you separated within the last 12 months, show the date of separation

(3)

NOT MARRIED (You have never married or are now divorced or widowed.) If your marriage ended within the last 12 months, show the date of divorce or death

3A. UNMARRIED DEPENDENT CHILDREN (Read Paragraph 1 of the EVR Instructions, VA Form 21P-0510)

FULL NAME OF EACH CHILD

DATE OF BIRTH

SOCIAL SECURITY

 

 

 

PLEASE CHECK ONE (X)

UNDER 18

OVER 18 AND UNDER

ANY AGE PERMANENTLY

(First, middle initial, last)

(Mo., day, yr.)

NUMBER

YEARS OF

23, AND ATTENDING

HELPLESS FOR MENTAL

 

 

 

AGE

SCHOOL

OR PHYSICAL REASONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3B. UNMARRIED DEPENDENT CHILDREN LISTED IN ITEM 3A WHO DO NOT LIVE WITH YOU

 

 

 

NAME OF EACH CHILD

 

CHILD'S COMPLETE

NAME OF PERSON

MONTHLY AMOUNT

 

 

 

 

CHILD LIVES WITH

YOU CONTRIBUTE TO

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

(If Applicable)

CHILD'S SUPPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

4A. ARE YOU A PATIENT IN A NURSING HOME?

 

4C. ENTER THE NAME, COMPLETE ADDRESS, AND TELEPHONE

 

 

 

 

 

 

 

 

NUMBER OF NURSING HOME (Please include Zip Code)

 

 

YES

 

 

NO (If "Yes," Complete Items 4B thru 4D. If "No," go to Item 5.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4B. SHOW THE DATE YOU ENTERED THE NURSING HOME

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

YES

 

NO

 

 

 

 

 

 

 

6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?

 

 

YES

 

 

NO (If "Yes," write in the VA file number of the other benefit.)

 

 

 

 

 

 

 

 

 

 

 

VA FORM

21P-0517-1

SUPERSEDES VA FORM 21-0517-1, APR 2015,

PAGE 1

JUN 2018

WHICH WILL NOT BE USED.

 

7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)

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

SOURCE

 

VETERAN

SPOUSE

CHILD:

 

 

 

 

 

SOCIAL SECURITY

$

$

 

$

U. S. CIVIL SERVICE

U. S. RAILROAD RETIREMENT

BLACK LUNG BENEFITS

MILITARY RETIREMENT

OTHER (Show Source)

OTHER (Show Source)

OTHER (Show Source)

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

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.

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

 

 

VETERAN

 

SPOUSE

CHILD:

 

 

 

 

 

 

 

 

SOURCE

FROM:

FROM:

FROM:

FROM:

FROM:

FROM:

 

THRU:

THRU:

THRU:

THRU:

THRU:

THRU:

GROSS WAGES FROM

$

$

$

$

$

$

ALL EMPLOYMENT

 

 

 

 

 

 

TOTAL INTEREST AND

 

 

 

 

 

 

DIVIDENDS

 

 

 

 

 

 

ALL OTHER

 

 

 

 

 

 

(Show Source)

ALL OTHER

(Show Source)

7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE 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)

 

 

YES

 

NO

(If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)

 

 

 

 

 

 

 

 

 

7D. WHAT INCOME CHANGED? (Show what

7E. WHEN DID THE INCOME CHANGE? (Show

7F. HOW DID INCOME CHANGE? (Explain what

 

income changed, for example, wages, city

the dates you received any new income or the

happened; for example, quit work, got raise,

 

 

 

pension, etc.)

date income changed)

received inheritance)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)

SOURCE

VETERAN

SPOUSE

CHILD:

 

 

 

 

CASH/NON- INTEREST-BEARING BANK ACCOUNTS

$

$

$

 

 

 

 

INTEREST-BEARING BANK ACCOUNTS

 

 

 

 

 

 

 

IRA'S, KEOGH PLANS, ETC.

 

 

 

 

 

 

 

STOCKS, BONDS, MUTUAL FUNDS, ETC.

 

 

 

 

 

 

 

REAL PROPERTY (Not your home)

 

 

 

 

 

 

 

ALL OTHER PROPERTY

 

 

 

 

 

 

 

8.MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)

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. 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.

9. VETERAN'S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR

$

Instructions) Show amounts paid by you during the past 12 months. DO NOT REPORT DEPENDENTS' EXPENSES.

 

 

 

10. FAMILY MAINTENANCE (Hardship) EXPENSES FOR THE NEXT 12 MONTHS (Read Paragraph 8 of the EVR

 

Instructions). Complete ONLY IF VA is currently excluding children's income on the grounds of hardship. Show total

$

family expenses expected for the next 12 months.

 

11A. SIGNATURE OF VETERAN (Read paragraph 9 of the EVR Instructions before signing)

11B. DATE SIGNED

 

11C. 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 21P-0517-1, JUN 2018

PAGE 2

How to Edit Va Form 21 0517 1 Online for Free

Handling PDF documents online is simple using our PDF tool. You can fill in form 0516 here in a matter of minutes. To have our editor on the leading edge of practicality, we work to implement user-driven features and improvements on a regular basis. We're always thankful for any feedback - assist us with reshaping the way you work with PDF forms. Getting underway is easy! All that you should do is follow these basic steps directly below:

Step 1: First of all, access the tool by clicking the "Get Form Button" at the top of this page.

Step 2: The tool enables you to work with PDF files in various ways. Transform it with personalized text, correct original content, and put in a signature - all doable in no time!

This PDF form requires particular data to be filled out, therefore be sure to take your time to type in precisely what is expected:

1. For starters, when filling out the form 0516, start with the area that includes the following blanks:

21 0516 1 conclusion process described (part 1)

2. Once your current task is complete, take the next step – fill out all of these fields - NOT MARRIED You have never married, If your marriage ended within the, show the date of divorce or death, A UNMARRIED DEPENDENT CHILDREN, FULL NAME OF EACH CHILD, First middle initial last, DATE OF BIRTH, Mo day yr, SOCIAL SECURITY, NUMBER, PLEASE CHECK ONE X, UNDER YEARS OF, OVER AND UNDER AND ATTENDING, AGE, and SCHOOL with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Stage # 2 of submitting 21 0516 1

3. In this step, examine C ENTER THE NAME COMPLETE ADDRESS, YES, If Yes Complete Items B thru D If, B SHOW THE DATE YOU ENTERED THE, D DOES MEDICAID COVER ALL OR PART, YES, DID EITHER YOU OR YOUR SPOUSE, YES, DO YOU RECEIVE ANY OTHER VA, YES, If Yes write in the VA file number, VA FORM JUL, SUPERSEDES VA FORM P JUN WHICH, and Page. Each one of these are required to be taken care of with greatest precision.

Completing segment 3 of 21 0516 1

4. This next section requires some additional information. Ensure you complete all the necessary fields - GROSS MONTHLY AMOUNTS If no income, A MONTHLY INCOME Read Paragraphs, SOURCE, VETERAN, SPOUSE, SOCIAL SECURITY, U S CIVIL SERVICE, U S RAILROAD RETIREMENT, BLACK LUNG BENEFITS, MILITARY RETIREMENT, OTHER Show Source, OTHER Show Source, OTHER Show Source, CHILD, and NOTE Report annual income for the - to proceed further in your process!

Step no. 4 for filling out 21 0516 1

5. Finally, the following last portion is precisely what you'll have to finish prior to using the PDF. The blanks under consideration include the following: GROSS WAGES FROM ALL EMPLOYMENT, ALL OTHER Show Source, C DID ANY INCOME CHANGE, YES, If YES complete Items D through F, D WHAT INCOME CHANGED Show what, income changed for example wages, pension etc, E WHEN DID THE INCOME CHANGE Show, the dates you received any new, date income changed, F HOW DID INCOME CHANGE Explain, happened for example quit work got, received inheritance, and G NET WORTH Read Paragraph of the.

The best way to fill out 21 0516 1 portion 5

When it comes to D WHAT INCOME CHANGED Show what and GROSS WAGES FROM ALL EMPLOYMENT, make sure you get them right in this section. Those two could be the most important fields in this PDF.

Step 3: Revise everything you've entered into the form fields and then click the "Done" button. Get your form 0516 when you register here for a 7-day free trial. Easily get access to the form within your personal account page, together with any modifications and changes all kept! We do not sell or share any details that you provide whenever completing forms at our website.

Va Form 21 0517 1 isn’t the one you’re looking for?

Related Documents