Form 21-509 at a glance
What it is: VA Form 21-509 is the Statement of Dependency of Parent(s).
Who signs: 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). Items 9A, 9B, 10A, 10B, 10C, and 10D are the dependents.
Use VA Form 21-509 if you are a veteran whose parents are dependent on you for support, and you are receiving compensation benefits based on a 30 percent or higher service-connected disability, or receiving VA educational benefits based on enrollment of 1/2 time or more.
Use the form also if you are the parent of a deceased veteran who died on active duty or as a result of service-connected injuries or disease prior to January 1, 1957, or died on or after May 1, 1957, and before January 1, 1972, while a waiver of premiums of his/her U.S. Government Life Insurance was in effect.
What to bring and attach to Form 21-509
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.
A filled-in Form 21-509 example: a veteran lists his mother
How to fill out Form 21-509, box by box
Name of Veteran and Full Name of Veteran's Parent
Enter the Name of Veteran (First Name, Middle Name, Last Name) and the VA File Number.
The term "Parent" includes a natural parent, a parent through adoption, and a foster parent (including stepparents who stood in the relationship of parent to the veteran).
Enter the Full Name of Veteran's Parent in 3A and 4A.
Enter the Date of Birth (MM/DD/YYYY) and the Social Security Number in 3B, 3C, 4B and 4C.
Enter the Date Parent Became Financially Dependent on the Veteran (MM/DD/YYYY) in 3D and 4D.
Net Worth
Report the current value of all the interest and rights you (the parent(s)) have in any kind of property. This includes real estate, stocks, bonds and the amount of bank deposits, savings and loan accounts, and cash on hand. However, net worth does not include your (the parent(s)) single family dwelling unit, reasonable lot area, and personal things you use every day like your vehicle, clothing, and furniture. If property is owned jointly by yourself and your spouse, report one-half of the total value held jointly for each of you.
Under 5. NET WORTH, enter A. Property (Include location of real property), B. Present Market Value (Dollar Amount) and C. Encumbrance on Property (Dollar Amount).
Income
Report all income received for the 12 month period and for the calendar month immediately preceding the date of completing this form, and the sources of income.
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.
Under 6. INCOME, enter A. Source from Which Income Is Received, B. Income for Latest Calendar Month from Each Source (Dollar Amount) and C. Total for 12 Months (Dollar Amount).
Expenses of Parent(s)
Enter the expenses of the parent(s), including spouse if remarried, for the 12 month period and for the calendar month immediately preceding the date of completing this form, and the purposes for which paid out.
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.
Under 7. Expenses of Parent(s), enter A. Type of Expense (List separately), B. Expenses for Last Calendar Month (Dollar Amount) and C. Total for 12 Months (Dollar Amount).
8. If expenses exceed income, state from what source such expenses are met.
Persons Solely Dependent upon Parent(s)
9A. PARENTS ONLY: are there any persons living in your household dependent solely upon you for support? YES (If "YES," complete 10A, 10B, 10C, and 10D) or NO.
9B. VETERANS ONLY: are there any persons living in your parent(s)' household dependent solely upon you for support? YES (If "YES," complete 10A, 10B, 10C, and 10D) or NO. Item 9B is to be completed by the veteran.
Under 10, enter A. Name of Dependent Persons, B. Date of Birth (MM/DD/YYYY), C. Relationship to Parent(s) and D. Reason for Dependency. If additional space is needed use separate sheet. Items 10A, 10B, 10C, and 10D are to be completed whenever the parent(s) have dependents residing with the parent(s).
Signature of Parent and of Veteran
Enter the DATE (MM/DD/YYYY) in 11A and 12A and sign in ink in 11B and 12B.
Enter the ADDRESS OF MOTHER, DAYTIME PHONE NUMBER and EVENING PHONE NUMBER in 11C, 11D and 11E, and the ADDRESS OF FATHER, DAYTIME PHONE NUMBER and EVENING PHONE NUMBER in 12C, 12D and 12E.
Enter the DATE (MM/DD/YYYY) in 13A, sign in ink in 13B, and enter the ADDRESS OF VETERAN, DAYTIME PHONE NUMBER and EVENING PHONE NUMBER in 13C, 13D and 13E.
If you sign by (X), your mark must be witnessed by two persons who know you personally and the signature and address of the witnesses must be shown in 14A, 14B, 15A and 15B.
More rules for Form 21-509
Item 9A is to be completed by the parent(s) of a deceased veteran. Items 7A, 7B, and 7C are the expenses of parent(s).
Print all answers clearly. If an answer is "none" or "0," write that. If you do not know the answer, write "unknown." If additional space is necessary, please attach a separate sheet with your answer.
If you have questions about this form, how to fill it out, or about benefits, contact your nearest VA regional office. You can locate the address of the nearest regional office at www.va.gov/directory or call 1-800-827-1000 (Hearing Impaired TDD line 711).
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)).
Common questions about Form 21-509
Is there a 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.
What am I certifying when I sign?
"I certify that the preceding statements are true and correct to the best of my knowledge and belief."
Sources
[1] VA Form 21-509 (MAY 2024), Statement of Dependency of Parent(s), U.S. Department of Veterans Affairs (the Official source link on this page).
