Form VA Form 21-527 VA Form 21-527 Income - Net Worth and Employment Statement

Income-Net Worth and Employment Statement

21-527n

Income-Net Worth and Employment Statement

OMB: 2900-0002

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2900-0002 can be found here:

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GENERAL INSTRUCTIONS
FOR INCOME-NET WORTH AND EMPLOYMENT STATEMENT
VA FORM 21-527
NOTE: Read very carefully, detach, and keep these instructions for your reference.

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

D. What is special monthly pension?

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.

VA may pay a higher rate of disability pension to a veteran
who is blind, a patient in a nursing home, otherwise needs
regular aid and attendance, or who is permanently confined to
his or her home because of a disability. If you wish to apply for
this benefit, check "Yes" for Item 24.

B. What do I use VA Form 21-527 for?

Furnish current medical evidence showing that you are
permanently and totally disabled.

Use VA form 21-527 to apply for disability pension if you have
previously filed a claim for compensation and/or pension. If you
have not filed a claim for compensation or pension previously, you
must use VA Form 21-526, Veteran’s Application for
Compensation and/or Pension.
C. What is disability pension and how does VA decide what I
will or will not receive?
You should apply for pension benefits if all of the following are
true:

.
.
.

Your income is limited.
You are permanently and totally disabled
(but not as a result of your military service).
At least part of your active duty was during a
wartime period.

VA pays disability pension based on the amount of income that
the veteran and family receive and the number of dependents in
the family. This is based on law. VA must include as income all
sources that federal law specifies. You can find out what the
current income limitations and rates of benefits are by contacting
your nearest VA office.

E. What medical evidence should I submit?

Note: If you are age 65 or older or determined to be disabled
by the Social Security Administration, you do not have to
submit medical evidence with your application unless you are
claiming special monthly pension.
If you wish to claim special monthly pension and are not in a
nursing home, furnish a statement from your doctor showing
the extent of your disabilities. If you are in a nursing home,
attach a statement signed by an official of the nursing home
showing the date you were admitted to the nursing home, the
level of care you receive, and whether Medicaid covers all or
part of your nursing home costs.
If you want help getting existing medical records, you may
complete VA Form 21-4142, Authorization and Consent to
Release Information to the Department of Veterans Affairs
(VA). By signing VA Form 21-4142, you authorize any doctors,
hospitals, or caregivers that have treated you to release
information about your treatment to VA. You do not need to
complete this form for any treatment you received at a VA
facility. If you need a copy of this form, you may contact VA as
shown under Item A, or download the form from our website at
http://www.va.gov/vaforms/.

F. How do I complete my application?
Benefits may only be paid from the date of receipt of your
application in VA unless you were incapacitated because of a
disability which prevented you from filing a claim for a period of at
least 30 days beginning with the date you became permanently
and totally disabled. If you want this claim considered as a claim
for retroactive payment, so indicate in Item 42, "Remarks," and
identify the specific disability which prevented you from filing.

VA FORM
JUN 2004

21-527

Print all answers clearly. If you must write the answers do so
very clearly and plainly. 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." For additional space, use Item 42, "Remarks," or
attach a separate sheet, indicating the item number to which
the answers apply. Make sure you sign and date this
application (Items 38 and 39).

EXISTING STOCKS OF VA FORM 21-527, FEB 1999,
WILL BE USED.

General Instructions Page 1

G. What do I do when I have completed my
application?
When you have completed this application mail it or take it to a VA
regional office. Be sure to attach any materials that support and
explain your claim. Also, make a photocopy of your application and
everything that you submit to VA before you mail it.
H. How can I assign someone to act as my representative?
A representative can be an accredited member of an accredited
organization or other service organization that the Secretary of
Veterans Affairs recognizes, an agent recognized by VA, or a
licensed lawyer. Agents and attorneys can charge you for services
that you get from them only after the Board of Veterans’ Appeals
(BVA) gives you their final decision about your application. That
means you can use an attorney during any stage of your application
for benefits. However, the agent or attorney cannot charge you for
services unless you are trying to resolve a dispute with VA after
BVA has made a decision about your claim.
If you want to use a representative to help you with your application,
contact the nearest VA office. Depending on the type of
representative you want to designate, we will send you one of the
following forms:

VA Form 21-22, Appointment of Veterans Service
Organization as Claimant’s Representative, or VA Form 22A,
Appointment of Individual as Claimant’s Representative. You
may download these forms at http://www.va.gov/vaforms/. If
you have already designated a representative, no further
action is required on your part.
I. What if I believe that VA has made a error in processing
or deciding my benefits?
You can ask for a personal hearing at any time during the
processing of your claim. That means you can ask for the
hearing while VA is processing your claim or after VA has
made a decision. You should contact the nearest VA office
and tell them that you want a personal hearing on your case.
Someone in the local VA office will arrange a time and place
for your hearing. At this hearing, you can bring witnesses. VA
will record whatever you and your witnesses say during the
hearing and include it in the official record. VA will furnish the
hearing room and officials, and prepare a transcript of the
hearing. VA cannot pay your expenses or the expenses of
anyone you want to bring with you to the hearing.

Privacy Act Notice: 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, 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). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN
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 for disability pension under 38 U.S.C. 1502 and 1503. Title 38,
United States Code, allows us to ask for this information. We estimate that you will need an average of 60 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. Valid OMB control numbers can be located on the OMB Internet Page at
www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to
send comments or suggestions about this form.

General Instructions Page 2

OMB Approved No. 2900-0002
Respondent Burden: 1 hour

(DO NOT WRITE IN THIS SPACE)

INCOME-NET WORTH AND EMPLOYMENT STATEMENT
VA Form 21-527
Please read the attached "General Instructions"before you fill out this form.

SECTION
I

Tell us
about
you

1. What is your name?
First

Middle

2. What is your social security number?

Last

Suffix (If applicable)

3. What is your VA file number?

4. What is your address?
Street address, rural route, or P.O. Box
City

Apt. number
State

5. What are your telephone numbers?

ZIP Code

Country

6. What is your E-mail address?

Daytime
Evening

Tell us

SECTION about
II
your
marriage

7. What is your marital status?
Married
Surviving spouse
Divorced
(If you are divorced, widowed or never married skip to Section III)

8. When were you married?
mo

NOTE: You
should
provide a
copy of your
marriage
certificate

day

Never married

9. Where did you get married? (city/state or country)

year

10. What is your spouse’s name?
First

Middle

Last

11. When is your spouse’s birthday?
mo

day

13a. Is your spouse also a veteran?
Yes

12. What is your spouse’s social security
number?

13b. What is your spouse’s VA file number?
(If any)

(If "Yes," answer Item 13b also)

14. Do you live with your spouse?
(If "No," answer Items 15 through 17 also. If "Yes," skip to Section III.)
Yes
No
15. What is your spouse’s address?
Street address, rural route, or P.O. Box

City

16.

Apt. number

State

Tell us why you are not living
with your spouse.

ZIP Code

Country

17. How much do you contribute
monthly to your spouse’s support?

VA FORM
JUN 2004

21-527

EXISTING STOCKS OF VA FORM 21-527,
FEB 1999 WILL BE USED.

21-527

Page 1

Tell us

SECTION about any
III
previous
marriages

You must furnish complete information about all of your and your present spouse’s previous
marriages. If you need additional space, please attach a separate sheet of paper providing the
requested information about the marriages.

Your previous marriages
18a. How many times have you been married?
18b. When
were you
married?

18c. Where were
you married?
(city/state or country)

18d. To whom married?

18e. Date
marriage ended

(first, middle initial, last name)

mo day yr

18f. Place

18g. How marriage
ended?

(city/state or country)

(death, divorce)

19f. Place

19g. How marriage
ended?

(city/state or country)

(death, divorce)

Your spouse’s previous marriages
19a. How many times has your current spouse been married?
19b. Date of
Marriage.

19c. Place
(city/state or country)

19d. To whom married?

19e. Date
marriage ended.

(first, middle initial, last name)

mo day yr

Tell us

SECTION about your
IV
unmarried
children

VA recognizes your biological children, adopted children, and stepchildren as
dependents. These children must be unmarried and:

.
..

under age of 18, or
between 18 and 23 and pursuing an approved course of education, or
of any age if they became permanently unable to support themselves before reaching
age 18.

"Seriously disabled" (Item 21h) means that the child became permanently unable to
support himself/herself before reaching age 18. Furnish a statement from an attending physician or
other medical evidence which shows the nature and extent of the physical or mental impairment.
If you need additional space, please attach a separate sheet of paper providing the requested
information about each child.

Note: You should provide a
copy of the public record of
birth for each child or a copy
of the court record of adoption
for each adopted child.

20. Do you have any dependent children?
Yes

(If "No," skip to Section V)

21-527

Page 2

SECTION
IV

Tell us about your unmarried children (Continued)

21a. Name of child
(First, middle initial, Last)

21b. Date and place of
birth
(City/State or Country)

21c. Social Security
Number

21d.
21e.
Biological Adopted

21g.
18-23 yrs.
old and in
school

21f.
Stepchild

21h.
Seriously
disabled

21I.
Child
previously
married

mo day yr
Place:

Tell us about the children listed above who don’t live with you
22a. Name of Child
(First, middle initial, last)

22c. Name of person the
child lives with
(If applicable)

22b. Child’s complete
address

22d. Monthly amount you
contribute to child’s support

$
$
$
Tell us
SECTION about
V
your
disability
and
background

23a. What disability(ies) prevent you from
working?

23b. When did the disability(ies) begin?

24. Are you claiming a special monthly
pension because you need the regular
assistance of another person, are blind,
nearly blind, or having severe visual
problems, or are housebound?

25a. Are you now, or have you recently
been hospitalized or given outpatient
or home-based care?

Yes

25b. Tell us the dates of the recent
hospitalization or care

"Yes," answer Items 25b
No (If
and 25c also)

Yes

day

25c. What is the name and complete
mailing address of the facility or doctor?

Began
mo

day

Ended

26a. Are you now employed?
Yes

(If "No," answer Item 26b
also)

26b. When did you last work?
mo

day

26c. Were you self-employed before becoming
totally disabled?
(If "Yes," answer Items 26d
Yes
No
and 26e also)

26d. What kind of work did you do?

26e. Are you still self-employed?

26f. What kind of work do you do now?

Yes

(If "Yes," answer Item 26f
also)
21-527

Page 3

SECTION V

Tell us about your disability and background (Continued)

27a. Check the highest year of education you completed:
Grade School:
1
2

College:
1

Over 4

27b. List the other training or experience you have and any certificates that you hold

Tell us

SECTION your
VI
work

history
28a. What was the name and
address of your employer?

In the table below, tell us about all of your employment, including
self-employment, for one year before you became disabled to the present.

28b. What was
your job
title?

28c. When did your
work begin?

28d. When did your
work end?

day

29c. Does Medicaid cover all or part of
your nursing home costs?
Yes

28f. What were your
total annual earnings?

Tell us if 29a. Are you now in a nursing home?
SECTION you are
Yes
No
in a
VII
nursing
(If "Yes," answer Item 29b also)
home
To get your claim
processed faster, provide a
statement by an official of
the nursing home that tells
us you are a patient in the
nursing home because of a
physical or mental disability
and tells us the amount you
pay out of pocket for your
care.

28e. How many
days were lost
due to
disability?

$
29b. What is the name and complete
mailing address of the facility?

29d. Have you applied for Medicaid?

Yes

(If "No," answer Item 29d also)

21-527

Page 4

VA cannot pay you pension if your net worth is sizeable. Net worth is the market value of all
interest and rights you have in any kind of property less any mortgages or other claims against
the property. However, net worth does not include the house you live in or a reasonable area of
land it sits on. Net worth also does not include the value of personal things you use everyday
like your vehicle, clothing, and furniture. If property is owned jointly by yourself and your
spouse, report one-half of the total value held jointly for each of you. You must report net worth
for yourself and all persons for whom you are claiming benefits.
For items 30A through 30f, provide the amounts. If none, write "0" or "None."

SECTION Tell us the
net worth of
VIII
you and
your
dependents

Child(ren)

Source

Veteran

Spouse

Name:
(first, middle initial, last)

30a. Cash, bank
accounts,
certificates of
deposit (CDs)

30b. IRAs, Keogh
Plans, etc.

30c. Stocks, bonds,
mutual funds

30d. Value of business
assets

30e. Real property (not
your home)

30f.All other property

Tell us

SECTION about the
IX
income
of you
and
your
dependents
Note: Payments from
any source will be
counted, unless the
law says that they
don’t need to be
counted. Report all
income, and VA will
determine any amount
that does not count.

Report the total amounts before you take out deductions for taxes, insurance, etc.
Do not report the same information in both tables.
If you expect to receive a payment, but you don’t know how much it will be, write
"Unknown" in the space.
If you do not receive any payments from one of the sources that we list, write "0" or
"None" in the space.
If you are receiving monthly benefits from any source, give us a copy of your most
recent award letter. This will help us determine the amount of benefits you should be
paid.

31. Have you claimed or are you receiving disability benefits from the Social Security
Administration (SSA)?

Yes

21-527

Page 5

SECTION Tell us about the income of you and your dependents
(Continued)
IX
Monthly Income - Tell us the income you and your dependents receive every month

Child(ren)

Sources of
recurring monthly
income

Veteran

Spouse

Name:
(first, middle initial, last)

32a. Social Security

32b. U.S. Civil Service

32c. U.S. Railroad
Retirement

32d. Military
Retirement

32e. Black Lung
Benefits

32f.Supplemental
Security Income (SSI)/
Public Assistance
32g. Other income
received monthly
(Please write source
below)

Expected income for the next 12 months - Tell us about other income for you and your dependents

Sources of
income for
the next
12 months

Child(ren)

Veteran

Spouse

Name:
(first, middle initial, last)

33a. Gross wages
and salary
33b. Total interest and
dividends
33c. Worker’s
compensation or
unemployment
compensation
33d. Other income
expected (Please write
source below)

21-527

Page 6

Family medical expenses and certain other expenses actually paid by you may be
SECTION Tell us
deductible from your income. Show the amount of unreimbursed medical expenses,
about
medical,
X

legal or other
unreimbursed
expenses

34a. Amount paid by
you

including the Medicare deduction, you paid for yourself or relatives who are members of
your household. Also, show unreimbursed last illness and burial expenses and
educational or vocational rehabilitation expenses you paid. Last illness and burial
expenses are unreimbursed amounts paid by you for the last illness and burial of a
spouse or child at any time prior to the end of the year following the year of death.
Educational or vocational rehabilitation expenses are amounts paid for courses of
education, including tuition, fees, and materials. Show medical, legal or other expenses
you paid because of a disability for which civilian disability benefits have been awarded.
When determining your income, we may be able to deduct them from the disability
benefits for the year in which the expenses are paid. Do not include any expenses for
which you were reimbursed. If more space is needed attach a separate sheet.

34b. Date paid

mo day yr

SECTION
XI

Give us
Direct
Deposit
Information

If benefits are
awarded we will need
more information in
order to process any
payments to you.
Please read the
paragraph starting
with, "All Federal
payments..." and then
either:

34c. Purpose
(Doctor’s fees, hospital
charges, attorney fees, etc.)

34d. Paid to
(Name of doctor, hospital
pharmacy, etc.)

34e. Disability or relationship of person
for whom expenses paid

All Federal Payments beginning January 2, 1999, must be made by electronic funds transfer
(EFT), also called Direct Deposit. Please attach a voided personal check or deposit slip or provide
the information requested below in Items 35, 36 and 37 to enroll in Direct Deposit. If you do not
have a bank account we will give you a waiver from Direct Deposit, just check the box below in
Item 35. The Treasury Department is working to make bank accounts available to you. Once
these accounts are available, you will be able to decide whether you wish to sign-up for one of the
accounts or continue to receive a paper check. You may also request a waiver if you have other
circumstances that you feel would cause you a hardship to be enrolled in Direct Deposit. You
may write to: Department of Veterans Affairs, 125 S. Main Street Suite B, Muskogee Ok 74401,
and give us a brief description of why you do not wish to participate in Direct Deposit.
35. Account number (Please check the appropriate box and provide that account number, if
applicable
Checking

I certify that I do not have an account with a financial
institution or certified payment agent

Savings

1. Attach a voided
check, or

Account number

36. Name of financial institution

2. Answer Items
35-37 to the right.
37. Routing or transit number

21-527

Page 7

SECTION Give us
XII
your
signature
1. Read the box that
starts, "I certify and
authorize the release
of information."
2. Sign the box that
says, "Your
signature."
3. If you sign with an
"X," then you must
have two people
witness it. They must
then sign the form
and print their names
and addresses also.

SECTION
XIII

I certify and authorize the release of information.
I certify that the statements in this document are true and complete to the best of my knowledge. I
authorize any person or entity, including but not limited to any organization, service provider,
employer, or government agency, to give the Department of Veterans Affairs any information about
me except protected health information, and I waive any privilege that makes the information
confidential.

38. Your signature

39. Today’s date
mo

day

40a. Signature of witness (If claimant
signed above using an "X")

40b. Printed name and address of witness

41a. Signature of witness (If claimant
signed above using an "X")

41b. Printed name and address of witness

42. Remarks (If you need more space to answer a question or have a comment about
a specific item number on this form, please identify your answer or statement by
the section and item number)

Remarks Use this
space for any
additional
statements
that you would like
to make concerning
your application for
compensation.

IMPORTANT
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 which you
are not entitled to.

21-527

Page 8

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File Modified	0000-00-00
File Created	0000-00-00