Va Form 21 0517 1 PDF Details

If you're a veteran who has been discharged from active duty or the National Guard, you may need to fill out VA Form 21-0517 in order to apply for disability compensation. This form is necessary in order to provide evidence that your disability is related to military service and therefore should be eligible for proper compensation based on your veteran status. The form itself can seem daunting, but it's not as complicated as it appears - this article will help make the process easier by explaining each of the fields that must be completed on VA Form 21-0517 and providing tips from veterans who have gone through the process themselves.

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

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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

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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.

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