Form 21P-527 INCOME, NET WORTH, AND EMPLOYMENT 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 711). You may also contact VA by the Internet at: https://iris.va.gov.
When do I use VA Form 21P-527?
Use VA Form 21P-527 to apply for disability pension if you have previously filed a claim for compensation and/or pension.
For. For. For. For. For. For.For expeditious processing under the Fully Developed Claim process use VA Form 21-527EZ,
Application for Pension. 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 permanently and totally disabled not necessarily as a result of your military service, or are age 65 or older
• 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 his/her family receive and 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 severe 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 36, "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 only those
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, 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 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) or VA Form 21-0779, Request for Nursing Home
Information in Connection with Claim for Aid and Attendance. 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 VA Form 21-4142 or VA Form
21-0779, you may contact VA as shown in "How can I contact VA if I have a question?" or download the forms from the VA
web site www.va.gov/vaforms.

VA FORM
XXX 2014

21P-527

SUPERSEDES VA FORM 21-527, JUL 2014,
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, for your records, 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
You may download these forms 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.
IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by
the place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you
filed your claim (or a later date when you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA
recognizes marriages is available at http://www.va.gov/opa/marriage/.

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, XXX 2014

Page 2

OMB Approved No. 2900-0002
Respondent Burden: 1 Hour
Expiration Date: XX/XX/XXXX

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'S IDENTIFYING INFORMATION
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or Print)
2B. VA FILE NO.

2A. VETERAN SOCIAL SECURITY NO.

3. ADDRESS OF VETERAN (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
XXX 2014

17B. PLACE OF
MARRIAGE

(City, State or Country)

21P-527

17C. NAME OF FORMER SPOUSE

(First, Middle, Last)

(Month, Day, Year)

SUPERSEDES VA FORM 21P-527, JUL 2014, WHICH
WILL NOT BE USED.

(City, State or Country)

17F. REASON
MARRIAGE
ENDED

(Death, Divorce)

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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)
19B. DATE
OF BIRTH

19A. NAME OF CHILD

(First, Middle, Last)

(Mo., Day, Yr.)

19C. PLACE
OF BIRTH

(City, State or
Country)

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

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

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

(First, Middle, Last)

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

20B. CHILD'S
COMPLETE ADDRESS

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

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

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

NO

24A. ARE YOU NOW EMPLOYED?
NO

NO

NO

VA FORM 21P-527, XXX 2014

(If "Yes," complete Items 23A & 23B)

23B. NAME AND MAILING ADDRESS OF FACILITY OR DOCTOR

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

24D. WHAT KIND OF WORK DID YOU DO?

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

24E. ARE YOU STILL SELF-EMPLOYED?
YES

NO

(If "No," complete Item 24B)

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

22B. ARE YOU NOW OR HAVE YOU BEEN RECENTLY HOSPITALIZED OR
GIVEN OUTPATIENT OR HOME CARE? (Due to the disability(ies) listed in
Item 21A)
YES

23A. DATE(S) OF RECENT HOSPITALIZATION OR CARE

YES

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

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

(If "Yes," complete Item 24F)
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PART IV - INFORMATION ABOUT YOUR DISABILITY AND BACKGROUND (Continued)
NOTE: In the table below, tell us about all of your employment, including self-employment, dating from one year before you
became disabled to the present.
25A. WHAT WAS THE NAME AND
ADDRESS OF YOUR EMPLOYER?

25B. WHAT WAS YOUR
JOB TITLE?

25C. WHEN DID
YOUR WORK
BEGIN?

(Mo., day, year)

25D. WHEN DID
25E. HOW MANY
25F. WHAT WERE
YOUR WORK END? DAYS WERE MISSED
YOUR TOTAL
(Mo., day, year) DUE TO DISABILITY? ANNUAL EARNINGS?

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

Grade school:
1

2

3

4

5

2

3

4

Over 4

6

7

8

9

10

11

12

College:
1

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

PART V - NURSING HOME INFORMATION
NOTE: To get your claim processed faster, 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. Also tell us the amount you pay out-of-pocket for your care.
27A. ARE YOU NOW IN A NURSING HOME?

YES

NO

(If "Yes," complete Item 27B)

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

NO

VA FORM 21P-527, XXX 2014

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

(If "No," complete 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. You must report net worth for yourself and all
persons for whom you are claiming benefits. VA cannot pay you a 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, liens 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. For Items 28A through 28F, provide the amounts. If none, write "0" or "None."
CHILD(REN)
Name

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

VETERAN

$

$

Interest
bearing:

$

y

n Interest
bearing:

Interest
bearing:

y

Interest
bearing:
Interest
bearing:

Name

(First, middle, last)

(First, middle, last)

SPOUSE

Name

(First, middle, last)

(First, middle, last)

$

$

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

n Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

Interest
bearing:

y

n

y

n Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

n Interest
bearing:

y

y

n Interest
bearing:

y

$

28E. Real property
(Not your home)
28F. All other property

PART VII - INFORMATION ABOUT YOUR AND YOUR DEPENDENTS' EXPECTED ANNUAL INCOME
IMPORTANT - Report 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, give your closest
estimate 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

VETERAN

SOURCE OF MONTHLY INCOME

30A. Gross Wages & Salary

$

(First, middle, last)

SPOUSE

$

Name

$

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, XXX 2014

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PART VIl - 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 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 VIII - 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, XXX 2014

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 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.
37A. SIGNATURE OF CLAIMANT

37B. DATE SIGNED

If signature of claimant made by "X" mark, you must have 2 people you know witness as you sign. They must then sign the form and print
their names and addresses.
38A. SIGNATURE AND PRINTED NAME OF WITNESS

38B. ADDRESS OF WITNESS

39A. SIGNATURE AND PRINTED NAME OF WITNESS

39B. 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, XXX 2014

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