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 | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | form 8049 print, va form 21 8049 fillable, va form 21p 8049, va form details |
OMB Approved No.
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
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 |
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Month |
Day |
Year |
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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 |
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Daytime |
Evening |
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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 |
SUPERSEDES VA FORM |
PAGE 1 |
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JAN 2020 |
WHICH WILL NOT BE USED. |
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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 |
$ |
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FOOD |
$ |
EDUCATION OF CHILDREN |
$ |
TAXES |
$ |
OTHER |
$ |
(Specify) |
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INTEREST |
$ |
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$ |
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CLOTHING |
$ |
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$ |
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?
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YES |
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NO |
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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
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 |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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$ |
$ |
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SECTION IX - COMMERCIAL LIFE INSURANCE PAYMENTS |
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NOTE: Under Public Law |
AMOUNT |
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veteran who dies after December 9, 2004. Proceeds from all other insurance payments may be countable. |
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19A. |
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TOTAL RECEIVED OR EXPECTED BY CLAIMANT |
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$ |
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19B. |
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EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments, explain payment schedule in |
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Item 12, Remarks) |
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19C. |
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NAME OF THE DECEASED FOR WHOM PAYMENT IS RECEIVED. |
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VA FORM |
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PAGE 2 |
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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. §§
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
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
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
VA FORM |
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