The term "income" means payments and benefits received from sources such as:
•Wages or salary (before any deductions) earned by all members of the parent(s)' household, including minors
•Actual contributions to the family by adult members outside of the household
•Social Security benefits, retirement pay, allotments, and family allowances
•Pension, compensation or insurance benefits (other than those received from the Department of Veterans Affairs)
•Interest and dividends
•Rents, property, business, and farm operations
When reporting net income for a business, farm, etc. attach a separate sheet showing gross income and itemized expenses. Net income is gross income less the expenses of operating a rental property or a business or farm. Gross income includes both receipts in cash and the market value of goods or services received in lieu of cash. Expenses include cost of goods sold (for businesses), normal repairs, taxes, salary or wages of employees, insurance, interest on business debts (but not payment of principal), supplies purchased, and other similar expenses.
Expenses of Parent(s) (Items 7A, 7B, 7C, and 8)
Report the expenses for the 12 month period and for the calendar month immediately preceding the date of completing this form. Include expenses for rent (or housing), home repairs, maintenance, clothing, medical care, utilities, groceries, taxes, etc.
Dependents (Items 9A, 9B, 10A, 10B, 10C, and 10D)
Item 9A is to be completed by the parent(s) of a deceased veteran. Item 9B is to be completed by the veteran. Items 10A, 10B, 10C, and 10D are to be completed whenever the parent(s) have dependents residing with the parent(s).
Note: Parent(s) must sign and date the form (Items 11A, 11B, 12A, and 12B). A veteran claiming his/her parent(s) as dependent(s) must also date and sign the form (Items 13A and 13B).
IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
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 38, Code of Federal Regulations 1.576 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, and published in the Federal Register. Your response 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. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). 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. 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. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). 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 to benefits for dependent parents. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 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 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.
