Va Form 21 509 – Fill Out and Use

INSTRUCTIONS

FOR STATEMENT OF DEPENDENCY OF PARENT(S)

VA FORM 21-509

Note: Read very carefully, detach, and keep these instructions for your reference. Print all answers clearly. If an answer is "none" or "0," write that. Your answer to every question is important to help us complete your claim. If you do not know the answer, write "unknown." If additional space is necessary, please attach a separate sheet indicating the item to which the answer applies.

A. How can I contact VA if I have questions?

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 in your telephone book blue pages under "United States Government, Veterans" or call 1-800-827-1000 (Hearing Impaired TDD line 1-800-829-4833). You may also contact VA by Internet at http://www.vba.va.gov/benefits/address.htm.

B. What do I use VA Form 21-509 for?

Use VA Form 21-509 if:

1. You are a veteran whose parents are dependent on for support, and you are:

OR

2.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.

C. What is meant by “Father” and “Mother” on this form?

The terms "Father" and "Mother" include a natural father or mother, a father or mother through adoption, and a foster father or mother (including stepparents who stood in the relationship of parent to the veteran).

Specific Instructions

Net Worth of Parent(s) (Items 5A, 5B, and 5C)

Report the current value of all the interest and rights you 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 single family dwelling unit and a reasonable lot area and personal things you use everyday like your vehicle, clothing, and fniture. If property is owned jointly by yourself and your spouse, report one-half of the total value held jointly for each of you.

Income of Parent(s) (Items 6A, 6B, and 6C)

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.

VA FORM	21-509	EXISTING STOCKS OF VA FORM 21-509, JUN 2004,
DEC 2010		WILL BE USED.

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).

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 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. 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 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.

VA FORM 21-509, DEC 2010

OMB Approved No. 2900-0089

Respondent Burden: 30 minutes

STATEMENT OF DEPENDENCY OF PARENT(S)

Important - Please read the attached instructions before completing this form.

5. NET WORTH

		A.		B.		C.
OWNER				PRESENT		ENCUMBRANCE
		DESCRIPTION OF PROPERTY (Include location of real property)
				MARKET VALUE		ON PROPERTY
			$		$
VETERAN'S
MOTHER

VETERAN'S

FATHER

PRESENT

SPOUSE

OF MOTHER

OR FATHER

6. INCOME

MEMBER				B.		C.
		A.		INCOME FOR LATEST		TOTAL FOR
OF
		SOURCE FROM WHICH INCOME IS RECEIVED		CALENDAR MONTH		12 MONTHS
FAMILY
				FROM EACH SOURCE
			$		$
VETERAN'S
MOTHER

VETERAN'S

FATHER

PRESENT

SPOUSE

OF MOTHER

OR FATHER

VA FORM	21-509	EXISTING STOCKS OF VA FORM 21-509, JUN 2004,
DEC 2010		WILL BE USED.

EXPENSES OF PARENT(S) (Including spouse if remarried)

INSTRUCTIONS - Enter below the expenses 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. Include expenses for rent (or housing), home repairs, maintenance, clothing, medical care, utilities, groceries, taxes, etc.

8. IF EXPENSES EXCEED INCOME, STATE FROM WHAT SOURCE SUCH EXPENSES ARE MET

9A. PARENTS ONLY - ARE THERE ANY PERSONS LIVING IN YOUR HOUSEHOLD DEPENDENT SOLELY UPON YOU FOR SUPPORT?

		YES		NO	(If "YES," complete Items 10A, 10B, 10C and 10D)
9B. VETERANS ONLY - ARE THERE ANY PERSONS LIVING IN YOUR PARENT(S)' HOUSEHOLD DEPENDENT SOLELY UPON YOU FOR SUPPORT?
		YES		NO	(If "YES," complete Items 10A, 10B, 10C and 10D)
				INFORMATION RELATING TO PERSONS SOLELY DEPENDENT UPON PARENT(S) (If additional space is needed use separate sheet)

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

11A. DATE	11B. SIGNATURE OF MOTHER		11C. ADDRESS OF MOTHER
11D. DAYTIME PHONE NUMBER	11E. EVENING PHONE NUMBER
12A. DATE	12B. SIGNATURE OF FATHER		12C. ADDRESS OF FATHER

WITNESSES - 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.

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 21-509, DEC 2010