Va Form 21 8049 – Fill Out and Use This PDF

The VA Form 21 8049 is used to apply for a Certificate of Eligibility (COE) that can be used in order to claim benefits from the Veterans Administration.

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Va Form 21 8049 PDF Details

Va form 21 8049 is a document that all military veterans should become familiar with. This form is used to apply for compensation and pension benefits, and it can be very helpful in ensuring that you receive the benefits that you deserve. In this blog post, we will discuss what VA form 21-8049 is and how to complete it. We will also provide tips on how to make the most of your claim and increase your chance of approval.

Here is some specifics that may help you find out how long it will require to complete the va form 21 8049.

Question	Answer
Form Name	Va Form 21 8049
Form Length	3 pages
Fillable?	Yes
Fillable fields	1
Avg. time to fill out	57 sec
Other names	va form 21 8049 pdf, va 21 8049, va form details, irs form 8049

12

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

Day

Year

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	21P-8049	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	$
		UTILITIES
FOOD	$	EDUCATION OF CHILDREN	$
TAXES	$	OTHER	$
TAXES	$	(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.				AMOUNT

	19A.		TOTAL RECEIVED OR EXPECTED BY CLAIMANT		$
	19A.		TOTAL RECEIVED OR EXPECTED BY CLAIMANT


	19B.		EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments, explain payment schedule in
	19B.		Item 12, Remarks)
			Item 12, Remarks)
	19C.		NAME OF THE DECEASED FOR WHOM PAYMENT IS RECEIVED.
	19C.

VA FORM 21P-8049, JAN 2020					PAGE 2
VA FORM 21P-8049, JAN 2020

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 form 8049 print 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 form 8049 print 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 8049

Feel free to type in your information in the field A, NAME C, RELATIONSHIP VA, FORM, JAN, P and PAGE.

va form 8049 ANAME, CRELATIONSHIP, VAFORMJANP, and PAGE fields to fill

Jot down the significant particulars in A, ITEM B, AMOUNT A, ITEM, Continued B, AMOUNT, Continued HOUSING, FOOD, TAXES, INTEREST, CLOTHING, UTILITIES, EDUCATION, OF, CHILDREN OTHER, Specify B, ESTIMATED, COST, PER, YEAR SECTION, VI, HOSPITAL, AND, MEDICAL, EXPENSES and YES segment.

Completing va form 8049 part 3

Please be sure to describe the rights and obligations of the sides inside the B, RELATIONSHIP, TO, YOU C, DATE, OF, DEATH EXPENDITURES, FOR, PERSON, NAMED, IN, ITEM, A SPOUSE, CHILD, PARENT, A, NAME, AND, ADDRESS, OF PERSON, TO, WHOM, PAID B, NATURE, OF, EXPENSES, OR, DEBT C, TOTAL, AMOUNT, OF, EXPENSES, OR, DEBT D, AMOUNT, PAID, BY, YOU E, DATE PAID, and AMOUNT section.

va form 8049 BRELATIONSHIPTOYOU, CDATEOFDEATH, EXPENDITURESFORPERSONNAMEDINITEMA, SPOUSE, CHILD, PARENT, ANAMEANDADDRESSOF, PERSONTOWHOMPAID, BNATUREOFEXPENSESORDEBT, CTOTALAMOUNTOFEXPENSESORDEBT, DAMOUNTPAIDBYYOU, EDATE, PAID, and AMOUNT fields to complete

Finish by taking a look at the next sections and filling them out as required: TOTAL, RECEIVED, OR, EXPECTED, BY, CLAIMANT VA, FOR, MP, JAN and PAGE.

Filling in va form 8049 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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