Form VA Form 21-0784 VA Form 21-0784 Supplemental Income Questionnaire (For Philippine Claims

OMB Control No. 2900-0668
Respondent Burden: 15 Minutes

SUPPLEMENTAL INCOME

~ Department of Veterans Affairs

(DO NOT WRITE IN THIS SPACE)

QUESTIONNAIRE
(For Philippine Claims Only)

Privacy Act Notice: VA will not disclose infonnation 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,
58VA21122128, Compensation, Pension, Education, and Vocational Rehabilitation and Employment 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 eligibility for pension benefits (38 U.S.c. 1521, 1541, and 1542).
Title 38, United States Code, allows us to ask for this informallon. We esllmate 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.
INSTRUCTIONS: Before further action can be taken on your claim for pension, we need more information about your income rom other sources. our answer to
every question is important to help us complete your claim. Please answer all questions fully and accurately, and print clearly. If an aJiswer is "none" or "0," write
that. Do not leave an uestions blan . S eci whether amounts are in dollars or e os.
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN
2. VA FILE NUMBER
3. FIRST - MIDDLE - LAST NAME OF CLAIMANT
(If olhor Ihon veloron)

PART I - SOURCES OF INCOIVIE
NOTE: Be sure to re ort in Part II the amounts of income received for an items marked "YES."
DO YOU OR YOUR DEPENDENTS:

YES

NO

4. OPERATE A SARI-SARI STORE?'
5. ENGAGE IN A BUY-AND-SELL BUSINESS?

6. OWN A FISHING BOAT?
7. IF YOU ANSWERED "YES" TO ITEM 6, DO YOU OR YOUR DEPENDENTS:
A. SELL PART OF THE CATCH?
B. RECEIVE PART OF THE CATCH AS RENT?
8. OWN FARM LANDS AND SELL THE PRODUCE, FRUITS, VEGETABLES, RICE, CORN, COCONUT, NIPA, BURl RATTAN,

BAMBOO, ANIMALS, ETC.?

9. IF YOU ANSWERED "YES" TO ITEM 8, DO YOU OR YOUR DEPENDENTS:
A. RECEIVE CASH FOR YOUR SHARE OF THE PRODUCE?
B. RECEIVE PART OF THE CROP AS YOUR SHARE?

10. RENT OUT ANY PART OF YOUR HOME OR APARTMENT?
11. OWN STOCKS?
12. HAVE A SAVINGS ACCOUNT?
13. HAVE SAVINGS CERTIFICATES?
14. HAVE GOVERNMENT (TREASURY) BONDS?

PART II-INCOME RECEIVED DURING THE LAST 12 MONTHS
MONTHLY INCOME Tell us the income ou and our de endents receive eve
SOURCES OF INCOME

VETERAN

SPOUSE
OR
WIDOW

CHILD

15. U.S. SOCIAL SECURITY
16. U.S. CIVIL SERVICE
17. MILITARY RETIRED PAY/SURVIVORS BENEFIT PLAN ANNUITY (SBP)
18. OTHER RETIREMENT BENEFITS (Please write in Ihe source below, i.e.,
Philipyine Governmenl Retirement, GS}S Retirement, Philippine Social Security,
PVAO Annuities
A.

B.
C.
D.

OTHER INCOME Tell us about other income

19. GROSS WAGES AND SALARY

20. TOTAL INTEREST AND DIVIDENDS RECEIVED ON SAVINGS ACCOUNTS,

TIME DEPOSITS, STOCKS, AND BONDS, ETC.

21. INCOME FROM RENTAL OF HOUSE OR APARTMENT
22. INCOME FROM RENTAL OF FARM OR RICE LAND (Give the peso equivalent

offarm products received)

VA FORM
JUL 2011

21-0784

EXISTING STOCKS OF VA FORM 21-0784, JUN 2005,
WILL BE USED.

(Continued on Reverse)

OTHER INCOME (Tell us about other income vou and your dependents receive.) (Continued)
SOURCES OF INCOME

VETERAN

SPOUSE
OR
WIDOW

CHILD

L;HILD

SPOUSE
OR
WIDOW

CHILD

CHILD

23. INCOME FROM FARM (Please write in the type ofproducts below, i.e., palay,
corn, coconut, copra, coffee, fruits, vegetables, etc., and give the peso equivalent
offarm products generated)

24. INCOME FROM BUSINESS
25. CONTRIBUTIONS FROM CHILDREN WHO ARE NOT YOUR DEPENDENTS
26. OTHER INCOME (Please write in the source below)

27. OTHER INCOME (Please write in the source belo1l1

PART III - NET WORTH
SOURCE

VETERAN

28. CASH, BANK SAVINGS ACCOUNTS
29. TIME DEPOSITS IN BANK
30. STOCKS AND BONDS
31. VALUE OF BUSINESS ASSETS AND INVESTMENTS
32. MARKET VALUE OF FARM
33. MARKET VALUE OF APARTMENT AND OTHER PROPERTIES
(Not your home unless part of it is rented)
34. REMARKS

CERTIFICATION
I CERTIFY THAT the statements in this document are true and complete to the best of my knowledge.
35A. SIGNATURE OF CLAIMANT (If cfaimant can write, then he or she ;nllst sign the name. If cfaimant cannot write then aJJix thllmbprint which m1lst be
witnessed by two person}> who can. write)

35B. TODAY'S DATE

..

WITNESSES TO SIGNATURE IF MADE BY THUMBPRINT
36A. SIGNATURE OF WITNESS (If cfaimant signed above by Ih/llnbWinl)

37A. SIGNATURE OF WITNESS (If cfai/llant signed ahove by Ihu/IIbWinl)

36B. PRINT NAME AND ADDRESS OF WITNESS

37B. PRINT NAME AND ADDRESS OF WITNESS

38 PRINT NAME AND ADDRESS OF PERSON WHO HELPED YOU COMPLETE THIS FORM (If applicabfe)

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 to which you are not entitled.
VA FORM 21-0784, JUL 2011