Va Form 21 8049 PDF Details

Filling out the VA 21-8049 form is a crucial step for individuals seeking to report detailed expenses to the Department of Veterans Affairs. This form is designed to collect comprehensive information regarding the expenses of veterans or claimants to determine their eligibility for benefits. It requires the submission of personal data, including the veteran's and claimant's name, social security numbers, and other identifying details, followed by thorough documentation of expenses such as housing, utilities, food, and medical expenditures. The process is outlined with clear instructions, ensuring that respondents understand the importance of providing accurate and full responses to each item. With an estimated completion time of just 15 minutes, the form respects the value of the respondent's time, yet its meticulous nature underscores the VA's commitment to ensuring that benefits are accurately awarded. Encouragement to use additional space or attach sheets for comprehensive answers, along with the option to complete the form online or by hand, provides flexibility to accommodate various respondents' preferences or needs. The form also touches on the sensitive subjects of last illness and burial costs, making it a document that covers almost every conceivable expense that could affect the financial situation of a veteran or their dependents. Through the VA 21-8049 form, detailed expense reporting is streamlined, assisting in the prompt and efficient processing of benefit entitlement determinations.

QuestionAnswer
Form NameVa Form 21 8049
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesva form 21 8049 fillable, irs form 8049, details expenses, va 21 8049

Form Preview Example

OMB Approved No. 2900-0138

Respondent Burden: 15 minutes

Expiration Date: 01/31/2023

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

REQUEST FOR DETAILS OF EXPENSES

IMPORTANT: Please read the Privacy Act and Respondent Burden on page 3 before completing the form.

For mailing information see Page 3 of the application.

INSTRUCTIONS - We need additional information to determine whether you are entitled to

benefits. Please complete all items. If an answer is "none" or "0" write that. For additional space, use Item 20, "Remarks," or attach a separate sheet indicating the item number to which the answers apply. If you have any questions or need assistance, please call 1-800-827-1000 (Hearing Impaired TDD line 711).

NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.

SECTION I: VETERAN'S PERSONAL INFORMATION (MUST COMPLETE)

1.VETERAN'S NAME (Last, first, middle)

2. VETERAN'S SOCIAL SECURITY NUMBER (SSN)

3. VA CLAIM NUMBER

4. VETERAN'S DATE OF BIRTH (MM,DD,YYYY)

Month DayYear

SECTION II: CLAIMANT'S PERSONAL INFORMATION (MUST COMPLETE)

5.CLAIMANT'S NAME (Last, first, middle)

6. CLAIMANT'S SOCIAL SECURITY NUMBER (SSN)

7. CLAIMANT'S DATE OF BIRTH (MM,DD,YYYY)

8. CLAIMANT'S RELATIONSHIP TO VETERAN

Month

Day

Year

 

9.CLAIMANT'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province

Country

City

ZIP Code/Postal Code

10. TELEPHONE NUMBER(S) (Include Area Code)

 

11. PREFERRED E-MAIL ADDRESS (Optional)

Daytime

Evening

 

 

 

 

SECTION III - DEPENDENTS NOT LIVING WITH YOU

 

 

(List ONLY persons you support who DO NOT live with you)

 

12A. NAME

12B. AGE

12C. RELATIONSHIP

12D. AMOUNT YOU CONTRIBUTE TO SUPPORT

$

$

$

$

$

SECTION IV - DEPENDENTS LIVING WITH YOU (List ONLY persons you support who DO live with you)

13A. NAME

13B. AGE

13C. RELATIONSHIP

VA FORM

21P-8049

SUPERSEDES VA FORM 21-8049, SEP 2016,

PAGE 1

JAN 2020

WHICH WILL NOT BE USED.

 

SECTION V - MONTHLY EXPENSES (EXCEPT MEDICAL)

FOR YOU AND THOSE LISTED IN ITEM 13A AS LIVING WITH YOU

14A. ITEM

14B. AMOUNT

14A. ITEM (Continued)

14B. AMOUNT(Continued)

HOUSING

$

UTILITIES

$

 

 

 

FOOD

$

EDUCATION OF CHILDREN

$

TAXES

$

OTHER

$

(Specify)

INTEREST

$

 

$

 

 

 

 

CLOTHING

$

 

$

SECTION VI - HOSPITAL AND MEDICAL EXPENSES

15A. DO YOU HAVE OR EXPECT TO HAVE ANY LARGE OR UNUSUAL HOSPITAL OR MEDICAL EXPENSES FOR YOURSELF AND OTHERS YOU SUPPORT AND LIVE WITH?

 

YES

 

NO

 

 

15B. ESTIMATED COST PER YEAR

$

15C. EXPLANATION

SECTION VII - EDUCATIONAL EXPENSES

16. DO YOU EXPECT TO MAKE PROVISIONS FOR YOUR CHILDREN'S EDUCATIONAL NEEDS, INCLUDING ADVANCED TECHNICAL OR COLLEGE EDUCATION?

YES

NO

SECTION VIII - EXPENSES OF LAST ILLNESS AND BURIAL OF VETERAN, SPOUSE, OR CHILD

AND JUST DEBTS OF DECEASED VETERAN OR PARENT'S SPOUSE

17A. NAME OF DECEASED PERSON (First-middle-last)

17B. RELATIONSHIP TO YOU

SPOUSE CHILD

PARENT

17C. DATE OF DEATH

EXPENDITURES FOR PERSON NAMED IN ITEM 17A

NOTE - Furnish information concerning unreimbursed expense as follows:

A VETERAN - For his/her spouse's or child's last illness and burial.

A CHILD - For veteran's last illness, burial and just debts.

A PARENT - For his/her spouse's or veteran's last illness and burial and for his/her spouse's just debts.

A SPOUSE - For the last illness and burial of veteran's child.

A WIDOW(ER) - For veteran's last illness, (paid before or after the veteran's death), burial and just debts and for the last illness and burial of veteran's child.

18A. NAME AND ADDRESS OF

PERSON TO WHOM PAID

18B. NATURE OF

EXPENSES OR DEBT

18C. TOTAL AMOUNT

18D. AMOUNT

18E. DATE

OF EXPENSES OR DEBT

PAID BY YOU

PAID

 

 

$

$

 

 

 

$

$

 

 

 

 

 

 

 

 

 

$

$

 

 

 

$

$

 

 

 

 

 

 

 

 

 

SECTION IX - COMMERCIAL LIFE INSURANCE PAYMENTS

 

 

 

 

 

 

NOTE: Under Public Law 108-454, VA may not count as income the lump sum proceeds of a life insurance policy on a

AMOUNT

 

veteran who dies after December 9, 2004. Proceeds from all other insurance payments may be countable.

 

 

 

 

 

19A.

 

TOTAL RECEIVED OR EXPECTED BY CLAIMANT

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19B.

 

EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments, explain payment schedule in

 

 

 

 

Item 12, Remarks)

 

 

 

 

 

 

 

 

19C.

 

NAME OF THE DECEASED FOR WHOM PAYMENT IS RECEIVED.

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 21P-8049, JAN 2020

 

PAGE 2

 

 

SECTION X - REMARKS, CERTIFICATION AND SIGNATURE

20. REMARKS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission or any statement or evidence of a material fact, knowing it to be false (18 U.S.C. §§ 1001-1002).

I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.

21A. SIGNATURE OF CLAIMANT (Do not print, sign in ink)

21B. DATE SIGNED

MAIL TO

Department of Veterans Affairs

Pension Intake Center

PO Box 5365

Janesville, WI 53547-5365

FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.

Privacy Act Information: The 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, Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. You are required to respond to obtain or retain benefits. The requested information is considered relevant and necessary to determine entitlement to benefits. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. You are required to provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may disclose them for purposes stated above.

Respondent Burden: We need this information to determine entitlement to pension or parent's dependency and indemnity compensation (38 U.S.C. 1503 and 1315). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 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.

VA FORM 21P-8049, JAN 2020

PAGE 3

How to Edit Va Form 21 8049 Online for Free

Filling out documents along with our PDF editor is more straightforward when compared with most things. To modify va form 21p 8049 the form, there is little you have to do - just adhere to the actions listed below:

Step 1: The webpage includes an orange button stating "Get Form Now". Press it.

Step 2: You'll notice each of the options that it's possible to undertake on the file once you've entered the va form 21p 8049 editing page.

In order to fill in the form, type in the details the program will require you to for each of the appropriate sections:

part 1 to filling in va form 21 8049 pdf

Feel free to type in your information in the field SECTION IV DEPENDENTS LIVING WITH, A NAME, B AGE, C RELATIONSHIP, VA FORM JAN P, SUPERSEDES VA FORM SEP WHICH, and PAGE.

va form 21 8049 pdf SECTION IV  DEPENDENTS LIVING WITH, A NAME, B AGE, C RELATIONSHIP, VA FORM JAN  P, SUPERSEDES VA FORM  SEP  WHICH, and PAGE fields to fill

Jot down the significant particulars in A ITEM, B AMOUNT, A ITEM Continued, B AMOUNTContinued, HOUSING, FOOD, TAXES, INTEREST, CLOTHING, UTILITIES, EDUCATION OF CHILDREN, OTHER Specify, A DO YOU HAVE OR EXPECT TO HAVE, B ESTIMATED COST PER YEAR, and SECTION VI HOSPITAL AND MEDICAL segment.

Completing va form 21 8049 pdf part 3

Please be sure to describe the rights and obligations of the sides inside the A NAME OF DECEASED PERSON, B RELATIONSHIP TO YOU, C DATE OF DEATH, EXPENDITURES FOR PERSON NAMED IN, SPOUSE, CHILD, PARENT, NOTE Furnish information, A SPOUSE For the last illness and, A VETERAN For hisher spouses or, A WIDOWER For veterans last, A NAME AND ADDRESS OF PERSON TO, B NATURE OF EXPENSES OR DEBT, C TOTAL AMOUNT OF EXPENSES OR DEBT, and D AMOUNT PAID BY YOU section.

va form 21 8049 pdf A NAME OF DECEASED PERSON, B RELATIONSHIP TO YOU, C DATE OF DEATH, EXPENDITURES FOR PERSON NAMED IN, SPOUSE, CHILD, PARENT, NOTE  Furnish information, A SPOUSE  For the last illness and, A VETERAN  For hisher spouses or, A WIDOWER  For veterans last, A NAME AND ADDRESS OF PERSON TO, B NATURE OF EXPENSES OR DEBT, C TOTAL AMOUNT OF EXPENSES OR DEBT, and D AMOUNT PAID BY YOU fields to complete

Finish by taking a look at the next sections and filling them out as required: NOTE Under Public Law VA may not, TOTAL RECEIVED OR EXPECTED BY, EXPECTED OR ACTUAL DATE OF RECEIPT, NAME OF THE DECEASED FOR WHOM, VA FORM P JAN, and PAGE.

Filling in va form 21 8049 pdf step 5

Step 3: Click the Done button to be certain that your completed document is available to be exported to each device you use or mailed to an email you indicate.

Step 4: To prevent yourself from any kind of difficulties as time goes on, you should create up to several copies of your document.

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