Va Form 21 4165 PDF Details

The VA Form 21-4165, known as the Pension Claim Questionnaire for Farm Income, serves a crucial purpose in assessing the eligibility and rightful benefits for veterans involved in farming activities. Recognized under the Office of Management and Budget (OMB) approval number 2900-0095, this form carries a respondent burden of approximately 30 minutes, emphasizing the importance of accuracy and completeness in providing information. As stipulated by the Privacy Act Notice, the Department of Veterans Affairs (VA) assures the confidentiality of the information provided, disclosing it only under authorized circumstances which are in compliance with federal laws for routine uses. This questionnaire encompasses a wide range of inquiries, from personal identification details like VA file numbers and social security numbers to comprehensive farm operation assessments including yearly gross receipts, farm operating expenses, and livestock information. It also probes into the extent of farm work conducted by the veteran, hired help, and others. This form not only facilitates the determination of eligibility for various pension benefits under distinct sections of 38 U.S.C. but also underscores the necessity for the veteran to disclose farm income accurately. Additionally, it outlines the legal implications of submitting false statements or evidence, reinforcing the significance of honesty and thoroughness in completing the questionnaire. The inclusion of provisions for certification and signatures further validates the authenticity of the information provided, ensuring the veteran's accountability.

QuestionAnswer
Form NameVa Form 21 4165
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesVBA 21 4165 ARE va form 21

Form Preview Example

OMB Approved No. 2900-0095 Respondent Burden: 30 minutes

PENSION CLAIM QUESTIONNAIRE

FOR FARM INCOME

1.VA FILE NUMBER C/SS-

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101

(c)(1). VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.

RESPONDENT BURDEN: We need this information to determine eligibility for disability pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1315, or death compensation under 38 U.S.C. 1121. We estimate that you will need an average 30 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at http:www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

INSTRUCTIONS: Before further action can be taken on your claim, we must have more information concerning your farming activity. Please answer all questions on this form accurately and completely. If the answer to a particular question is none, write "NONE" in the space provided.

References in this form to "THIS YEAR" refer to the period

(If blank, "THIS YEAR" refers to the current calendar year. References to "LAST YEAR" refer to the 12 month period preceding "THIS YEAR".)

PERIOD STARTING DATE

PERIOD ENDING DATE

2. FIRST - MIDDLE - LAST NAME OF VETERAN

3. SOCIAL SECURITY NUMBER

4. VA OFFICE AND ADDRESS

5. REPORT OF THE TOTAL OF ALL GROSS RECEIPTS

(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, etc.)

A. AMOUNT RECEIVED LAST YEAR

$

B. AMOUNT EXPECTED THIS YEAR

$

C. AMOUNT ANTICIPATED NEXT YEAR

$

6. NAMES OF OWNERS OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH (As shown by deed, trust or other document)

7. FARM OPERATING EXPENSES

(Include landlord's share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)

ITEM

AMOUNT

AMOUNT TO

 

ITEM

AMOUNT

AMOUNT TO

SPENT LAST

BE SPENT

 

SPENT LAST

BE SPENT

(A)

YEAR

THIS YEAR

 

(D)

YEAR

THIS YEAR

 

(B)

(C)

 

 

(E)

(F)

HIRED LABOR

 

 

 

OTHER EXPENSES (List)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEEDS PURCHASED

 

 

 

 

 

 

 

 

 

 

 

 

 

SUPPLIES PURCHASED

 

 

 

 

 

 

 

 

 

 

 

 

 

MACHINE HIRE

 

 

 

 

 

 

 

 

 

 

 

 

 

REPAIRS AND MAINTENANCE

 

 

 

 

 

 

OF FARM BUILDINGS AND

 

 

 

 

 

 

MACHINERY (Except dwellings)

 

 

 

 

 

 

CASH RENT

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY TAXES

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE ON PROPERTY

 

 

 

 

 

 

 

 

 

 

 

 

 

INTEREST ON MORTGAGE

 

 

 

 

(COLS. B AND E)

(COLS. C AND F)

AND OTHER LOANS

 

 

 

TOTAL EXPENSES

$

$

(Not payment on principal)

 

 

 

 

 

 

 

 

 

 

 

VA FORM

21-4165

EXISTING STOCKS OF VA FORM 21-4165, APR 2004,

DEC 2010

 

WILL BE USED.

8A. TOTAL ACREAGE OWNED BY YOU

8B. ACREAGE RENTED TO OTHERS

8C. ACREAGE RENTED FROM

 

OTHERS

8D. TOTAL ACREAGE OPERATED BY YOU

9. ACREAGE IN CROPS AND PASTURE

10. LIVESTOCK INFORMATION

KIND

(Grain, hay, cotton, tobacco, etc.)

NUMBER OF ACRES

KIND

LAST YEAR

THIS YEAR

(Cattle, pigs, sheep, ducks, etc.)

TOTAL NUMBER ON FARM NOW

PASTURE

11. TOTAL FARM WORK

(Furnish the following information about the work done by you, hired help and others)

YEAR

 

LINE

 

ITEM

 

 

PROPORTION (Check applicable boxes)

 

 

 

 

 

 

 

 

 

 

(C)

 

 

 

 

 

 

 

 

(A)

 

NO.

 

(B)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NONE

1/4

 

1/2

 

3/4

 

ALL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

PROPORTION DONE BY YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

PROPORTION DONE BY HIRED HELP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

PROPORTION DONE BY OTHERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Including members of the family)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

PROPORTION BEING DONE BY YOU

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THIS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

PROPORTION BEING DONE BY HIRED HELP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

PROPORTION BEING DONE BY OTHERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Including members of the family)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. PLEASE DESCRIBE ANY WORK YOU HAVE DONE FOR OTHERS DURING THE PAST YEAR AND THE AMOUNT OF SALARY OR WAGES YOU RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. DO YOU RENT YOUR FARM TO OR FROM SOMEONE ELSE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO (If "Yes", furnish a copy of your farm rental agreement or lease or a statement setting forth in detail particulars of the agreement)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. DO YOU RECEIVE INCOME FROM ANY SOURCE OTHER THAN FARMING?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO (If "Yes", explain fully, including income received)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERTIFICATION AND SIGNATURE OF CLAIMANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15A. DATE SIGNED

 

15B. SIGNATURE OF CLAIMANT

16. ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15C. DAYTIME PHONE NO. (Including Area Code)

15D. EVENING PHONE NO. (Including Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and addresses of such witnesses must be shown below.

17A. SIGNATURE OF WITNESS

17B. PRINTED NAME AND ADDRESS OF WITNESS

18A. SIGNATURE OF WITNESS

18B. PRINTED NAME AND ADDRESS OF WITNESS

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 to be false, or for the fraudulent acceptance of any payment to which you are not entitled.

VA FORM 21-4165, DEC 2010

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This form needs specific information; in order to guarantee correctness, please make sure to adhere to the suggestions hereunder:

1. Whenever completing the Va Form 21 4165, ensure to complete all of the important blank fields within the relevant section. This will help to hasten the process, allowing your details to be processed promptly and appropriately.

Part no. 1 of completing Va Form 21 4165

2. Given that the last array of fields is completed, you're ready to put in the required particulars in A AMOUNT RECEIVED LAST YEAR, B AMOUNT EXPECTED THIS YEAR, C AMOUNT ANTICIPATED NEXT YEAR, NAMES OF OWNERS OF BUSINESS AND, Include landlords share for all, FARM OPERATING EXPENSES, ITEM, AMOUNT, SPENT LAST, YEAR, AMOUNT TO, BE SPENT THIS YEAR, ITEM, OTHER EXPENSES List, and AMOUNT so that you can move on further.

Va Form 21 4165 completion process detailed (step 2)

3. Completing PROPERTY TAXES, INSURANCE ON PROPERTY, INTEREST ON MORTGAGE AND OTHER, VA FORM DEC, TOTAL EXPENSES, Cols B and E, Cols C and F, and EXISTING STOCKS OF VA FORM APR is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

How one can prepare Va Form 21 4165 stage 3

A lot of people generally make some errors when filling out INSURANCE ON PROPERTY in this area. Don't forget to revise everything you type in right here.

4. This particular section comes next with the next few fields to fill out: A TOTAL ACREAGE OWNED BY YOU, B ACREAGE RENTED TO OTHERS, C ACREAGE RENTED FROM OTHERS, D TOTAL ACREAGE OPERATED BY YOU, ACREAGE IN CROPS AND PASTURE, KIND, NUMBER OF ACRES, LIVESTOCK INFORMATION, KIND, Grain hay cotton tobacco etc, LAST YEAR, THIS YEAR, Cattle pigs sheep ducks etc, TOTAL NUMBER ON FARM NOW, and PASTURE.

Writing part 4 in Va Form 21 4165

5. Last of all, this final part is what you have to finish prior to using the document. The blanks you're looking at are the following: PROPORTION BEING DONE BY OTHERS, PLEASE DESCRIBE ANY WORK YOU HAVE, DO YOU RENT YOUR FARM TO OR FROM, YES, If Yes furnish a copy of your farm, DO YOU RECEIVE INCOME FROM ANY, YES, If Yes explain fully including, I CERTIFY THAT the foregoing, A DATE SIGNED, B SIGNATURE OF CLAIMANT, ADDRESS, CERTIFICATION AND SIGNATURE OF, C DAYTIME PHONE NO Including Area, and D EVENING PHONE NO Including Area.

Va Form 21 4165 conclusion process described (part 5)

Step 3: Prior to finalizing this document, check that all blank fields have been filled in properly. As soon as you determine that it's fine, click “Done." Join FormsPal now and easily access Va Form 21 4165, prepared for downloading. Each and every modification made is handily kept , allowing you to customize the form at a later point if required. FormsPal is invested in the confidentiality of our users; we always make sure that all personal data going through our system is kept secure.