Form VA Form 21P-4165 VA Form 21P-4165 Pension Claim Questionnaire For Farm Income

OMB Approved No. 2900-0095
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX
1. VA FILE NUMBER

PENSION CLAIM QUESTIONNAIRE
FOR FARM INCOME

C/SS-

INSTRUCTIONS: Before further action can be taken on your claim, we must have more information concerning your farming activity. Please
answer all questions on this form accurately and completely. If the answer to a particular question is none, write "NONE" in the space provided.
Please read the Privacy Act and Respondent Burden Information on Page 2 before completing this form.
References in this form to "THIS YEAR" refer to the period
(If blank, "THIS YEAR" refers to the current calendar year.
References to "LAST YEAR" refer to the 12 month period
preceding "THIS YEAR".)
4. NAME OF VETERAN (First, Middle, Last)

3. PERIOD ENDING DATE

2. PERIOD STARTING DATE

6. SOCIAL SECURITY NUMBER OF CLAIMANT

5. NAME OF CLAIMANT (First, Middle, Last)

7. REPORT OF THE TOTAL OF ALL GROSS RECEIPTS

(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, etc.)
B. AMOUNT EXPECTED THIS YEAR

A. AMOUNT RECEIVED LAST YEAR
$

C. AMOUNT ANTICIPATED NEXT YEAR
$

$
8. NAME(S) OF OWNER(S) OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH

(As shown by deed, trust or other document)

A. NAME OF OWNER OF BUSINESS

B. DEGREE OF OWNERSHIP

9. FARM OPERATING EXPENSES
(Include landlord's share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)
(A) AMOUNT SPENT LAST YEAR

(B) AMOUNT SPENT LAST YEAR

(C) AMOUNT SPENT THIS YEAR

HIRED LABOR
FEEDS PURCHASED
SUPPLIES PURCHASED
MACHINE HIRE
REPAIRS AND MAINTENANCE OF FARM BUILDINGS AND MACHINERY

(Except dwellings)
CASH RENT

PROPERTY TAXES
INSURANCE ON
PROPERTY
INTEREST ON MORTGAGE AND OTHER LOANS

(Not payment on principal)

TOTAL EXPENSES
VA FORM
XXX XXXX

21P-4165

$

SUPERSEDES VA FORM 21-4165, JUN 2013,
WHICH WILL NOT BE USED.

$

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10A. PROVIDE THE TOTAL ACREAGE OWNED BY YOU?

10B. IS YOUR PRIMARY RESIDENCE LOCATED ON THE ACREAGE YOU OWN?
YES

NO

(If "Yes", complete Items 7C and 7D)

10D. WHAT IS THE SPECIFIC VALUE OF THE ACREAGE RELATED TO YOUR
PRIMARY RESIDENCE?

10C. HOW MANY OF THE ACRES YOU OWN ARE CONSIDERED
PART OF YOUR PRIMARY RESIDENCE?

$

11. ACREAGE IN CROPS AND PASTURE
NUMBER OF ACRES

(A) KIND

(Grain, hay, cotton, tobacco, etc.)

12. LIVESTOCK INFORMATION

(B) LAST YEAR

(A) KIND

(C) THIS YEAR

(Cattle, pigs, sheep, ducks, etc.)

(B) TOTAL NUMBER
ON FARM NOW

PASTURE
13. DO YOU RENT YOUR FARM TO OR FROM SOMEONE ELSE?
YES

NO

(If "Yes", furnish a copy of your farm rental agreement or lease or a statement setting forth in detail particulars of the agreement)

14. REMARKS (If any)

CERTIFICATION AND SIGNATURE OF CLAIMANT

I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15A. SIGNATURE OF CLAIMANT
17A. DAYTIME PHONE NO. (Including Area Code)

15B. DATE SIGNED

16. ADDRESS

17B. EVENING PHONE NO. (Including Area Code)

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK

Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and
addresses of such witnesses must be shown below.
18A. SIGNATURE OF WITNESS

18B. PRINTED NAME AND ADDRESS OF WITNESS

19A. SIGNATURE OF WITNESS

19B. PRINTED NAME AND ADDRESS OF WITNESS

PRIVACY ACT NOTICE: 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 5, Code of Federal
Regulations 1.526 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, 58VA21/22/28, 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. 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 the purposed stated above. 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.
RESPONDENT BURDEN: We need this information to determine eligibility for disability pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1521, death pension under 38 U.S.C.
1315, death compensation under 38 U.S.C. 1121, or Parents' dependency and indemnity compensation under 38 U.S.C. 1315. 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.reginfo.gov/public/do/
PRAMain. If desired, you can call 1-877-294-6380 to get information on where to send comments or suggestions about this form.
VA FORM 21P-4165, XXX XXXX

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