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

GENERAL INSTRUCTIONS
FOR INCOME- NET WORTH AND EMPLOYMENT STATEMENT
NOTE: Read these instructions very carefully, detach, and keep for your reference.
Frequently Asked Questions
How can I contact VA if I have a question?
If you have questions about this form, how to complete it, or about benefits, contact your nearest VA regional office. You can
locate the address of the nearest VA regional office on the Internet at www.va.gov/directory, in your telephone book blue
pages under "United States Government, Veterans." For information you may also call 1-877-294-6380 (Hearing Impaired
TDD line 1-800-829-4833). You may also contact VA by the Internet at: https://iris.va.gov.
When do I use VA Form 21-527?
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. For expeditious processing, use VA Form 21-527EZ, Fully Developed Claim (Pension).
All VA forms are available at www.va.gov/vaforms.
What is disability pension and how does VA decide what I will and will not receive?
You should apply for pension benefits if all of the following are true:

• Your income is limited
• You are age 65 or older or are permanently and totally disabled (not as a result of your military service)
• You had at least 90 days active duty during a wartime period
VA pays disability pension based on the amount of income that the veteran and family receive, taking into account the
number of dependents in the family. VA must include all sources of income that Federal law specifies. You can find out what
the current income limitations and rates of benefits are by contacting your nearest VA office.
VA may pay benefits from the date of receipt of your application unless disability prevented you from filing a claim for a
period of at least 30 days. If you want this claim considered for retroactive payment, indicate so in Item 37, "Remarks," and
identify the specific disability which prevented you from filing.
What is special monthly pension?
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" in Item 22A.
What medical evidence should I submit?
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. Otherwise, provide medical records
that are related to the disabilities that prevent you from working.
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, or VA Form 21-0779, Request for Nursing Home
Information in Connection with Claim for Aid and Attendance, 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 VA's help getting medical records related to this claim 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 the form, you may contact VA as
shown in "How can I contact VA if I have a question?", or download the form from the VA website www.va.gov/vaforms.
VA FORM
JUN 2012

21P-527

SUPERSEDES VA FORM 21-527, JUN 2004,
WHICH WILL NOT BE USED.

Page 1

GENERAL INSTRUCTIONS (Continued)
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. You can locate the mailing address of
your nearest VA regional office at www.va.gov/directory. 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.
How can I assign someone to act as my representative?
An accredited representative of a veteran's organization or other service organization recognized by the Secretary of
Veterans Affairs may represent you without charge. An accredited attorney or agent may also represent you. However under
38 U.S.C. 5904(c), an accredited agent or attorney may only charge you for services performed after the date you file a
notice of disagreement.
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 21-22A, Appointment of Individual as Claimant's Representative
These forms are also available at: www.va.gov/vaforms. If you have already designated a representative, no further action is
required on your part.
Net Worth
VA considers all of your (and your spouse's) assets ("net worth") in determining your eligibility for non service-connected
pension. Transferring your cash or property to another person, trust, organization, corporation or any other entity does not
reduce your net worth in order to qualify for pension unless it is clear that you have permanently given up all rights of
ownership, including the right to control the cash or property. In completing this form, you must tell us about all assets you
have transferred in the last two (2) years, along with any assets you transferred previously for any period of time if the value
of the asset(s) exceeded a total of $20,000. Note the conditions of transfer in Item 36, "Remarks," including any remaining
right, privilege of ownership, benefit, or control you have over the asset.

PRIVACY ACT INFORMATION: The form will be used to determine allowance to pension benefits (38 U.S.C. 5101). The
responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you provide,
including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act, including the routine
uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. The requested information is considered
relevant and necessary to determine maximum benefits under the law. Information submitted is subject to verification
through computer matching programs with other agencies. VA may make a "routine use" disclosure for: 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. Your obligation to respond is
required in order to obtain or retain benefits. 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. Social Security information: 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 your eligibility for pension. Title 38, United States Code,
allows us to ask for this information. We estimate that you will need an average of 1 hour 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-527, JUN 2012

Page 2

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

INCOME, NET WORTH, AND EMPLOYMENT STATEMENT
IMPORTANT - Read Privacy Act and Respondent Burden Information and Instructions carefully before
completing the form. Type, print, or write plainly.

(DO NOT WRITE IN THIS SPACE)
(VA DATE STAMP)

PART I - VETERAN/CLAIMANT INFORMATION

1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN/CLAIMANT (Type or Print)
2B. VA FILE NO.

2A. VETERAN/CLAIMANT SOCIAL SECURITY NO.

3. ADDRESS OF VETERAN/CLAIMANT (Number, street or rural route, City or P.O., State and ZIP Code)

4A. TELEPHONE NUMBER(S) (Include Area Code)
DAYTIME

EVENING

4B. E-MAIL ADDRESS (If applicable)

CELL

PART II - MARITAL INFORMATION

NOTE: If married, you should provide a copy of your marriage certificate.
5. WHAT IS YOUR MARITAL STATUS?
MARRIED

WIDOWED

DIVORCED

(If you are divorced or widowed skip to Item 14)
(If never married skip to Part III)

NEVER MARRIED

6A. WHEN WERE YOU MARRIED? (Month, day, year)

6B. WHERE DID YOU GET MARRIED? (City, State or Country)

7. SPOUSE'S NAME (First, middle, last)

8. SPOUSE'S BIRTHDAY (Month, day, year)

10B. SPOUSE'S VA FILE NO. (If any)

10A. IS YOUR SPOUSE ALSO A VETERAN?
YES

NO

(If "Yes," complete Item 10B, if known)

9. SPOUSE'S SOCIAL SECURITY NO.

11. DO YOU LIVE WITH YOUR SPOUSE?
YES

12. SPOUSE'S ADDRESS (Number and street or rural route, city or P.O., State

and ZIP Code)

NO

(If "Yes," skip to Item
14) (If "No," complete
Items 12, 13A & 13B)

13A. IF YOU DO NOT LIVE WITH YOUR
13B. HOW MUCH DO YOU
SPOUSE PLEASE PROVIDE THE REASON
CONTRIBUTE MONTHLY
TO SPOUSE'S SUPPORT?
(i.e., illness, work, etc.)

$
INFORMATION ABOUT THE VETERAN'S & SPOUSE'S PREVIOUS MARRIAGES
NOTE: Furnish the following 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.
14. HOW MANY TIMES HAVE YOU BEEN MARRIED?

15A. DATE OF
MARRIAGE

(Month, Day, Year)

15B. PLACE OF
MARRIAGE

(City, State or Country)

15C. NAME OF FORMER SPOUSE

(First, Middle, Last)

15D. DATE
MARRIAGE ENDED

15E. PLACE
MARRIAGE ENDED

(Month, Day, Year)

(City, State or Country)

17D. DATE
MARRIAGE ENDED

17E. PLACE
MARRIAGE ENDED

15F. REASON
MARRIAGE
ENDED

(Death, Divorce)

16. HOW MANY TIMES HAS YOUR CURRENT SPOUSE BEEN MARRIED?

17A. DATE OF
MARRIAGE

(Month, Day, Year)

VA FORM
JUN 2012

17B. PLACE OF
MARRIAGE

(City, State or Country)

21P-527

17C. NAME OF FORMER SPOUSE

(First, Middle, Last)

(Month, Day, Year)

EXISTING STOCKS OF VA FORM 21-527, JUN 2004,
WILL BE USED.

(City, State or Country)

17F. REASON
MARRIAGE
ENDED

(Death, Divorce)

Page 3

PART III - INFORMATION ABOUT YOUR UNMARRIED DEPENDENT CHILDREN
VA recognizes your biological children, adopted children, and stepchildren as dependents. These children must be unmarried and:
• under age 18, or
• between 18 and 23 and pursuing an approved course of education, or
• of any age if they became seriously disabled and permanently unable to support themselves before reaching age 18.
"Seriously disabled" 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.

INFORMATION ABOUT THE CHILDREN WHO LIVE WITH YOU
18. DO YOU HAVE ANY DEPENDENT CHILDREN?
YES

NO

(If "No," skip to Part IV)

(First, Middle, Last)

19C. PLACE
OF BIRTH

19B. DATE
OF BIRTH

19A. NAME OF CHILD

(Mo., Day, Yr.)

(City, State or
Country)

19E. CHECK EACH APPLICABLE CATEGORY
19D. SOCIAL
SECURITY
NUMBER

18-23 YRS.
CHILD
OLD AND SERIOUSLY
BIOLOGICAL ADOPTED STEPCHILD
PREVIOUSLY
ATTENDING DISABLED
MARRIED
SCHOOL

INFORMATION ABOUT THE CHILDREN WHO DO NOT LIVE WITH YOU
20A. NAME OF CHILD

20B. CHILD'S
COMPLETE ADDRESS

(First, Middle, Last)

20C. NAME OF PERSON CHILD
LIVES WITH (If applicable)

20D. MONTHLY AMOUNT
YOU CONTRIBUTE
TO CHILD'S SUPPORT

$
$
$
$
PART IV - INFORMATION ABOUT YOUR DISABILITY
21A. WHAT DISABILITY (IES) PREVENT YOU FROM WORKING?

22A. ARE YOU CLAIMING A SPECIAL MONTHLY PENSION BECAUSE YOU NEED
THE REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL
PROBLEMS, OR ARE HOUSEBOUND?
YES

NO
23A. DATE(S) OF RECENT HOSPITALIZATION OR CARE

21B. WHEN DID THE DISABILITY(IES) BEGIN? (Month, Day, Year)

22B. ARE YOU NOW OR HAVE YOU BEEN RECENTLY HOSPITALIZED OR
GIVEN OUTPATIENT OR HOME CARE? (THIS PERTAINS ONLY TO
HOSPITALIZATION, OUTPATIENT, OR HOMEBASED CARE DUE TO THE
DISABILITIES LISTED IN ITEM 21A ABOVE)
YES
NO (If "Yes," complete Items 23A & 23B)
23B. NAME AND MAILING ADDRESS OF FACILITY OR DOCTOR

PART V - INFORMATION ABOUT YOUR EMPLOYMENT AND EDUCATION
24A. ARE YOU NOW EMPLOYED?
YES

NO

(If "No," answer Item 24B)

24C. WERE YOU SELF-EMPLOYED BEFORE BECOMING TOTALLY DISABLED?
YES

NO

NO

24D. WHAT KIND OF WORK DID YOU DO?

(If "Yes," answer Items 24D and 24E)

24E. ARE YOU STILL SELF-EMPLOYED?
YES

24B. WHEN DID YOU LAST WORK? (Month, Day, Year)

24F. WHAT KIND OF WORK DO YOU DO NOW?

(If "Yes," answer Item 24F)

VA FORM 21P-527, JUN 2012

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PART V - INFORMATION ABOUT YOUR EMPLOYMENT AND EDUCATION (Continued)

NOTE: In the table below, tell us about all of your employment, including self-employment, for one year before you became disabled
to the present.
25A. WHAT WAS THE NAME AND
ADDRESS OF YOUR MOST RECENT EMPLOYER?

25B. WHAT WAS YOUR
JOB TITLE?

25C. WHEN DID
YOUR WORK
BEGIN?

(Mo., day, year)

25D. WHEN DID
YOUR WORK END?

(Mo., day, year)

25E. HOW MANY
25F. WHAT WERE
DAYS WERE LOST
YOUR TOTAL
DUE TO DISABILITY? ANNUAL EARNINGS?

$
$
$
$
$
$
26A. CHECK THE HIGHEST YEAR OF EDUCATION YOU COMPLETED:

Grade school:
1

2

3

4

5

6

2

3

4

Over 4

7

8

9

10

11

12

College:
1

26B. LIST THE OTHER TRAINING OR EXPERIENCE YOU HAVE AND ANY CERTIFICATES THAT YOU HOLD

PART VI - NURSING HOME INFORMATION
NOTE: Provide a statement by an official of the nursing home that tells VA that 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.
27A. ARE YOU NOW IN A NURSING HOME?

YES

NO

(If "Yes," answer Item 27B)

27C. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME COSTS?
YES

NO

VA FORM 21P-527, JUN 2012

27B. WHAT IS THE NAME AND COMPLETE MAILING ADDRESS OF THE
FACILITY?

(If "No," answer Item 27D)

27D. HAVE YOU APPLIED FOR MEDICAID?
YES

NO

Page 5

PART Vl - INFORMATION ABOUT THE NET WORTH OF YOU AND YOUR DEPENDENTS
NOTE: VA must generally consider all assets in determining eligibility for non-service connected pension. VA cannot pay
you pension if your net worth is substantial. 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. VA does not allow anyone to transfer cash, property, or any other asset in order to
qualify for non-service connected pension. 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. You do not reduce net worth for VA purposes as long as you maintain some right, privilege of ownership, benefit,
or control of asset.
For Items 28A through 28F, provide the amounts. If none, write "0" or "None."
CHILD(REN)
Name

SOURCE OF ASSETS

28A. Cash, bank accounts,
certificates of deposit (CDs)
28B. IRAs, Keogh Plans, etc.

28C. Stocks, bonds, mutual funds

28D. Value of business assets
28E. Real property
(Not your home)
28F. All other property

VETERAN

$

(First, middle, last)

SPOUSE

$

Name

$

Name

(First, middle, last)

$

Name

(First, middle, last)

$

(First, middle, last)

$

Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

PART VlI - INFORMATION ABOUT THE INCOME OF YOU AND YOUR DEPENDENTS
IMPORTANT - VA will count payments from any source, unless the law says not to count them. Report all income and its sources and
VA will determine whether to count it.

NOTE: 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, give us a copy of your most recent award letter. This will help us determine the amount of
benefits we should pay you.
29. HAVE YOU CLAIMED OR ARE YOU RECEIVING DISABILITY BENEFITS FROM THE SOCIAL SECURITY ADMINISTRATION (SSA)?
YES

NO

MONTHLY INCOME - TELL US THE INCOME YOU AND YOUR DEPENDENTS RECEIVE EVERY MONTH
CHILD(REN)
Name

SOURCE OF MONTHLY INCOME

30A. Gross Wages & Salary

VETERAN

$

$

Name

(First, middle, last)

SPOUSE

$

Name

(First, middle, last)

$

Name

(First, middle, last)

$

(First, middle, last)

$

30B. Social Security
30C. U.S. Civil Service
30D. U.S. Railroad Retirement
30E. Military Retirement
30F. Black Lung Benefits
30G. Supplemental Security Income
(SSI)/Public Assistance
30H. Other income received
monthly (Please write source below)

VA FORM 21P-527, JUN 2012

Page 6

PART VlI - INFORMATION ABOUT YOU AND YOUR DEPENDENTS EXPECTED ANNUAL INCOME (Continued)
EXPECTED INCOME FOR THE NEXT 12 MONTHS - TELL US ABOUT OTHER INCOME YOU AND YOUR DEPENDENTS EXPECT TO RECEIVE
CHILD(REN)
SOURCE OF INCOME FOR THE
NEXT 12 MONTHS

31A. Total interest and dividends

VETERAN

$

Name
(First, middle, last)

SPOUSE

$

$

Name
(First, middle, last)

$

Name
(First, middle, last)

$

Name
(First, middle, last)

$

31B. Worker's compensation or
unemployment compensation
31C. Other income expected
(Please write source below)

PART VlII - INFORMATION ABOUT YOUR MEDICAL, LEGAL OR OTHER UNREIMBURSED EXPENSES
NOTE: Family medical expenses and certain other expenses you actually paid may be deductible from your income. Show the amount of
unreimbursed medical expenses, including the Medicare deduction, you paid over the last year 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 you paid 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 you paid for courses of education including
tuition, fees, and materials. Show medical, legal or other expenses you paid because of a disability for which you were awarded civilian
disability benefits. 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.
32A. AMOUNT YOU
PAID

32B. DATE PAID
(Month, day, year)

32C. PURPOSE (Doctor's fees, hospital
charges, attorney fees, etc.)

32D. PAID TO
(Name of doctor, hospital,
pharmacy, etc.)

32E. DISABILITY OR
RELATIONSHIP OF
PERSON FOR WHOM
EXPENSES PAID

$
$
$
$
PART IX - DIRECT DEPOSIT INFORMATION
If benefits are awarded we will need more information in order to process any payments to you. Please read the paragraph below
and then either:
1. Attach a voided check, or
2. Answer Items 33-35.
The Department of Treasury requires all Federal benefit payments 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 in Items 33, 34 and 35 to enroll in direct deposit. If you do not have a bank
account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard you must apply at
www.usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to enroll, you must contact representatives handling waiver requests for the
Department of Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any questions or concerns you may have.
33. ACCOUNT NUMBER - PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE THE ACCOUNT NUMBER, IF APPLICABLE
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR A
CHECKING
SAVINGS
CERTIFIED PAYMENT AGENT

ACCOUNT NUMBER
34. NAME OF FINANCIAL INSTITUTION
35. ROUTING OR TRANSIT NUMBER

VA FORM 21P-527, JUN 2012

Page 7

PART X - REMARKS
36. REMARKS - USE THIS SPACE FOR ANY ADDITIONAL STATEMENTS THAT YOU WOULD LIKE TO MAKE CONCERNING YOUR APPLICATION

PART XI - CERTIFICATION AND SIGNATURE
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
which makes the information confidential.
37. SIGNATURE OF CLAIMANT

38. DATE SIGNED

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK (If you sign with an "X" then you must have 2 people you know witness
you as you sign. They must then sign the form and print their names and addresses.
39A. SIGNATURE AND PRINTED NAME OF WITNESS

39B. ADDRESS OF WITNESS

40A. SIGNATURE AND PRINTED NAME OF WITNESS

40B. ADDRESS OF WITNESS

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 21P-527, JUN 2012

Page 8