Form VA Form 21-0512s-1 VA Form 21-0512s-1 Old Law and Section 306 Eligibility Verification Report

OMB Approved No. 2900-0101
Respondent Burden: 30 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN

OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
2S
(SURVIVING SPOUSE)

FIRST, MIDDLE, LAST NAME OF SURVIVING SPOUSE

VA FILE NUMBER
COMPLETE MAILING ADDRESS OF SURVIVING SPOUSE

VA REGIONAL OFFICE RETURN ADDRESS

IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21-0510) before completing this form. This form
is used by surviving spouses receiving Old Law or Section 306 Pension. If you have been receiving a fixed rate of
pension since 1960, you receive Old Law Pension. If you have been receiving a fixed rate of pension since 1978, you
receive Section 306 Pension. If you receive Old Law Pension, do not complete Item 7G, Net Worth, and Item 8,
Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1A. VETERAN’S SOCIAL SECURITY NUMBER

1B. YOUR SOCIAL SECURITY NUMBER

1C. YOUR DATE OF BIRTH (Mo., day, yr.)

2. MARITAL STATUS (Check one box)
(1)

I HAVE NOT REMARRIED SINCE THE VETERAN DIED (You have not married anyone since the veteran’s death)

(2)

I REMARRIED ON
(Date) AND I AM STILL MARRIED (You married after the veteran’s death and you are
currently married. Enter the date you married your current spouse.)

(3)

I REMARRIED AFTER VETERAN DIED BUT MARRIAGE ENDED BY DEATH OR DIVORCE ON
(You remarried but you are not currently married.) Show the date your latest marriage ended.)

3A. NUMBER OF UNMARRIED DEPENDENT CHILDREN (See Paragraph 1 of the EVR Instructions)
IN YOUR CUSTODY

(Date)

3B. AMOUNT CONTRIBUTED DURING PAST 12
MONTHS TO CHILDREN NOT IN YOUR CUSTODY

NOT IN YOUR CUSTODY

$
4A. ARE YOU A PATIENT IN A NURSING HOME? (If "YES," Complete Items 4B thru 4D) If "NO," go to Item 5.)
YES

NO

4B. SHOW THE DATE YOU ENTERED THE NURSING HOME

4C. ENTER THE NAME, COMPLETE ADDRESS, AND TELEPHONE
NUMBER OF NURSING HOME
(Please include ZIP Code)

4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?

YES

NO

5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE LAST 12 MONTHS?

YES

NO

6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?

YES
VA FORM
JUN 2004

NO

(If you checked "YES," write in the VA File number of the other benefit)

21-0512s-1

SUPERSEDES VA FORMS 21-0511S-1, AUG 2000 AND
21-0512S-1, JUN 2002, WHICH WILL NOT BE USED.

(Continued on Reverse)

REPORT OF INCOME AND NET WORTH
If you have no income or net worth from a particular source, write "0"or "none". DO NOT LEAVE ANY ITEMS BLANK.
7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
SOURCE

GROSS MONTHLY AMOUNTS
$

SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY INCOME
(SSI)/PUBLIC ASSISTANCE
OTHER MONTHLY INCOME
(Show Source)

7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
If no income was received from a particular source, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
SOURCE

LAST YEAR

GROSS WAGES FROM ALL EMPLOYMENT

THIS YEAR

$

$

INTEREST AND DIVIDENDS
ALL OTHER (Show Source)
ALL OTHER (Show Source)
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE PAST 12 MONTHS? (Answer "NO" if there were no income changes or if the
only change was a Social Security/VA cost-of-living adjustment. Answer "YES" if there were any other income changes of if you received any
NEW source of income or any ONE-TIME income)
(1)

YES

(2)

NO (If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)

7D. WHAT INCOME CHANGED?
7E. WHEN DID THE INCOME CHANGE?
7F. HOW DID INCOME CHANGE?
(Show what income changed; for example, wages, (Show the dates you received any new income or (Explain what happened: for example, quit work, got
city pension, etc.)
the date income changed)
raise, received inheritance)

7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)

NOTE: Complete only if you receive Section 306 Pension. Skip to Item 9A if you receive Old Law Pension.
SOURCE

SURVIVING SPOUSE

CASH/NON-INTEREST BEARING BANK ACCOUNTS

$

INTEREST BEARING BANK ACCOUNTS
IRAs, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY
(Not your home)
ALL OTHER PROPERTY
8. FAMILY MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)

NOTE: Skip to Item 9A if you receive Old Law Pension.

If Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21-8416,
Medical Expense Report, to report your medical expenses.
9A. SIGNATURE OF CLAIMANT, CUSTODIAN OR GUARDIAN (Read paragraph 6 of the EVR Instructions before signing)

9B. DATE

10. TELEPHONE NUMBERS (Include Area Code)
DAYTIME

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.