Va Form 21 8049 – Fill Out and Use

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

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?

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

AND JUST DEBTS OF DECEASED VETERAN OR PARENT'S SPOUSE

EXPENDITURES FOR PERSON NAMED IN ITEM 17A

		$		$
		$		$
		$		$
		$		$
			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.

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

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