Form VA Form 21-0788 VA Form 21-0788 Information Regarding Apportionment of Beneficiary's Awa

OMB Approved No. 2900-0666
Respondent Burden: 30 minutes
(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

INFORMATION REGARDING APPORTIONMENT OF
BENEFICIARY’S AWARD
INSTRUCTIONS: All or part of a veteran’s disability award may be apportioned (paid) to the veteran’s spouse, child, or
dependent parent. A surviving spouse’s award may also be apportioned for the veteran’s child or children. Print all answers
clearly. If an answer is "none" or "0," write that or line through the space provided. For additional space, attach a separate
sheet, indicating the item number to which the answers apply. Make sure to write the veteran’s name and VA claim number on
any attachments to the form.
1. FIRST, MIDDLE, LAST NAME OF VETERAN

2. VA FILE NUMBER
C/CSS-

3. FIRST, MIDDLE, LAST NAME OF PERSON COMPLETING THIS FORM (If other than veteran)

4A. WHO ARE YOU REQUESTING AN APPORTIONMENT FOR? (List first, middle, and last names)

4B. WHAT IS HIS/HER RELATIONSHIP TO THE
VETERAN?

5A. HOW MUCH IS THE VETERAN OR VETERAN’S SURVIVING SPOUSE CONTRIBUTING TO THE
PERSON(S) FOR WHOM AN APPORTIONMENT IS BEING CLAIMED?

5B. HOW OFTEN ARE THE CONTRIBUTIONS MADE?

$
6. IF THE SPOUSE IS CLAIMING AN APPORTIONMENT, IS HE/SHE LIVING WITH ANOTHER PERSON
AND HOLDING HIMSELF/HERSELF OUT OPENLY TO THE PUBLIC AS THE SPOUSE OF THE OTHER
PERSON?
(If "Yes," provide an explanation below)

YES

7. HAS THE VETERAN’S CHILD(REN) BEEN
LEGALLY ADOPTED BY ANOTHER PERSON?

NO
YES

NO

PART I - INCOME AND NET WORTH
Report all income and net worth. Report the gross amounts before you take out deductions for taxes, insurance, etc. If you do not
receive income or net worth from a particular source, write "0" or "none" in the space provided. Do not leave the space blank.
Note: If you are the veteran or surviving spouse, report only your income and net worth. If you are the claimant or are filing on behalf of the
claimant(s), report all income and net worth for all persons for whom an apportionment is being claimed. If you are claiming an apportionment
as the custodian of the veteran’s child or children, report your income and net worth and the income and net worth of the child(ren).
MONTHLY INCOME
SOURCE
1A. GROSS WAGES FROM ALL
EMPLOYMENT

VETERAN OR
SURVIVING SPOUSE
$

CUSTODIAN

$

PERSON APPORTIONMENT IS
CLAIMED FOR

PERSON APPORTIONMENT
IS CLAIMED FOR

$

$

PERSON APPORTIONMENT IS
CLAIMED FOR

PERSON APPORTIONMENT
IS CLAIMED FOR

$

$

1B. SOCIAL SECURITY
1C. RETIREMENT OR ANNUITIES
1D. SUPPLEMENTAL SECURITY
INCOME (SSI)/ PUBLIC ASSISTANCE
1E. OTHER INCOME (Show source)
1F. OTHER INCOME (Show source)
NET WORTH
SOURCE
2A. CASH/NON-INTEREST-BEARING
BANK ACCOUNTS
2B. INTEREST-BEARING BANK
ACCOUNTS
2C. IRAS, KEOGH PLANS, ETC.
2D. STOCKS, BONDS, MUTUAL
FUNDS, ETC.
2E. REAL PROPERTY
(Not your home)
2F. ALL OTHER PROPERTY AND
ASSETS
VA FORM
JAN 2005

21-0788

VETERAN OR
SURVIVING SPOUSE
$

CUSTODIAN

$

PART II - MONTHLY LIVING EXPENSES
Show your monthly living expenses, including any monthly installment payments. If you do not have expenses from a particular source,
write "0" or "none" in the space provided. Do not leave the space blank.
Note: If you are the veteran or surviving spouse, report only your expenses. If you are the claimant or are filing on behalf of the claimant(s),
report expenses for all persons for whom an apportionment is being claimed. If you are claiming an apportionment as the custodian of the
veteran’s child or children, report your expenses and the expenses of the child(ren).
SOURCE

VETERAN OR
SURVIVING SPOUSE

CUSTODIAN

PERSON APPORTIONMENT IS PERSON APPORTIONMENT IS
CLAIMED FOR
CLAIMED FOR

1A. RENT OR HOUSE PAYMENT
$

$

$

$

1B. FOOD

1C. UTILITIES
(Water, gas, electricity)
1D. TELEPHONE

1E. CLOTHING

1F. MEDICAL EXPENSES

1G. SCHOOL EXPENSES

1H. OTHER EXPENSES
(Show source)
1I. OTHER EXPENSES
(Show source)

PART III - CERTIFICATION AND SIGNATURE
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
1. SIGNATURE OF VETERAN OR CLAIMANT

2. DATE SIGNED

3. TELEPHONE NUMBERS (Include Area Code)
A. DAYTIME

B. EVENING

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 is false, or fraudulent acceptance of any payment to which you are not entitled.
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, 58VA 21/22/28, Compensation,
Pension, Education and Rehabilitation Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. 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 submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN - We need this information to determine whether an apportionment of VA disability or death benefits may be made (38 U.S.C. 5307). Title
38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 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.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.