Va Form 21 0518 1 – Fill Out and Use

	OMB Control No. 2900-0101
	Respondent Burden: 30 minutes
	Expiration Date: 06/30/2021
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN
FIRST NAME - MIDDLE NAME - LAST NAME OF SURVIVING SPOUSE	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 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.)

(2)		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.)

(3)		I REMARRIED AFTER THE VETERAN DIED BUT THE MARRIAGE ENDED BY DEATH OR DIVORCE ON	.
		(You remarried but you are not currently married. Show the date your latest marriage ended.)

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

IN YOUR CUSTODY						NOT IN YOUR CUSTODY
AMOUNT CONTRIBUTED DURING PAST 12 MONTHS TO CHILDREN NOT IN YOUR CUSTODY $
4A. ARE YOU A PATIENT IN A NURSING HOME?									4C. ENTER THE NAME, COMPLETE ADDRESS, AND
									TELEPHONE NUMBER OF NURSING HOME
		YES		NO (If "Yes", Complete Items 4B thru 4D. If "No", go to Item 5.)					(Please include Zip Code)
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 YOU RECEIVE ANY WAGES OR WERE 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-0518-1				SUPERSEDES VA FORM 21-0518-1, APR 2015,		PAGE 1
JUN 2018							WHICH WILL NOT BE USED.

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."

SOURCE	SURVIVING SPOUSE
SOCIAL SECURITY	$
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
OTHER (Show Source)
OTHER (Show Source)

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.

SOURCE	FROM:	FROM:
	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 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.)

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

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-0518-1, JUN 2018

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