Form 21P-527 Income, Asset, and Employment Statement

GENERAL INSTRUCTIONS
FOR INCOME, ASSET 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 http://www.va.gov/directory, or 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 veterans pension if you have previously filed a claim for compensation and/or veterans
pension. For expeditious processing under the Fully Developed Claim process use VA Form 21P-527EZ, Application for
Veterans Pension. VA forms are available at www.va.gov/vaforms.
What is veterans pension and how does VA decide what I will and will not receive?
You should apply for veterans pension benefits if all of the following are true:

• Your income and assets do not exceed certain limits. Visit our website at www.benefits.va.gov/pension/rates.asp for
the maximum yearly income we allow.

• You are 65 or older or permanently and totally disabled. Your disabilities do not have to be related to your military
service.

• You served on active duty with at least one day during a period of war. Visit our website at
www.benefits.va.gov/pension/vetpen.asp for more specific information.

VA pays veterans pension based on income and asset amounts for the veteran and his/her dependents. 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.
You must provide information about the Social Security benefits you and your dependents receive. Report the gross amount
you and your dependents receive monthly before deductions are taken out. If you have a copy of your most recent Social
Security award letter, please include a copy of the letter with your application.
You must tell us if you or your dependents receive or received income from sources other than Social Security. Please
also report if you or your dependents own your primary residence and the value of your assets and your dependents' assets.
Your assets do include your spouse's assets. Although your assets do not include your child's assets, you must tell us if
your child has significant assets.
Assets means the fair market value of all property that an individual owns, including all real and personal property
(excluding the value of the primary residence including the residential lot area, not to exceed 2 acres) less the amount of
mortgages or other encumbrances specific to the mortgaged or encumbered property. Personal property means the value
of personal effects that are in excess of being suitable and consistent with a reasonable mode of life. You must tell us if
you or your dependents have transferred assets in the past three calendar years.
IMPORTANT: If you or your dependents receive or received income in addition to Social Security benefits or you or your
dependents have significant assets or have transferred assets, we will require you to complet VA Form 21P-0969, Income
and Asset Statement, in addition to this application.
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.

VA FORM
XXX 2014

21P-527

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

Page 1

GENERAL INSTRUCTIONS (Continued)
What is special monthly pension?
Special monthly pension is an increased amount paid to individuals who, due to mental or physical disability, require the aid
of another person to perform activities of daily living, are a patient in a nursing home, have severe visual problems, or are
substantially confined to his or her home. If you wish to apply for this benefit, check "Yes" in Item 22A.
What medical evidence should I submit?
If you are you are a veteran who is claiming pension and 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, please complete and attach with this application,
VA Form 21-2680, Exam for Housebound Status or Permanent Need for Regular Aid and Attendance. Please make sure
every box is complete and the application is signed by a physician, physician assistant (PA), certified nurse practitioner
(CNP), or clinical nurse specialist (CNS). If you are in a patient in a nursing home, please attach a completed 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 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 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.
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?
A VA-accredited representative of a veteran's service organization or other service organization recognized by the Secretary
of Veterans Affairs may represent you without charge. A VA-accredited attorney or claims 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.
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 VA
recognized marriages is available at http://www.va.gov/opa/marriage/.

VA FORM 21P-527, XXX 2014

Page 2

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 3

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

INCOME, ASSET, 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 VA Form 21-686c, Declaration of Status of Dependent, 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, 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, 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)

Page 4

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?
19B. DATE
OF BIRTH

19A. NAME OF CHILD

(First, Middle, Last)

(Mo., Day, Yr.)

YES

NO

19C. PLACE
OF BIRTH

(City, State,
Country)

(If "No," skip to Part IV)

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
NOTE: If you are a veteran who is claiming pension and you are age 65 or older, or determined disabled by the Social Security Administration, you DO NOT have to submit
medical evidence with your application unless you are claiming special monthly pension.
21A. WHAT DISABILITY(IES) PREVENT YOU FROM WORKING?

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

22A. ARE YOU CLAIMING SPECIAL MONTHLY PENSION BECAUSE YOU NEED THE
REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL
PROBLEMS, OR ARE GENERALLY CONFINED TO YOUR IMMEDIATE PREMISES?
YES
NO (If "Yes," complete and attach with this application VA Form 21-2680,
Exam for Housebound Status or Permanent Need for Regular Aid and
Attendance. Please make sure every box is completed and signed by a
Physician, Physician Assistant (PA),Certified Nurse Practitioner (CNP),
or Clinical Nurse Specialist (CNS.)

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)

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

23B. NAME AND MAILING ADDRESS OF FACILITY OR DOCTOR

24A. ARE YOU NOW EMPLOYED?
YES

NO

NO

NO

VA FORM 21P-527, XXX 2014

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

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

YES

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

(If "Yes," complete Item 24F)
Page 5

PART IV - INFORMATION ABOUT YOUR DISABILITY(IES) 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.
25B. WHAT WAS YOUR
JOB TITLE?

25A. WHAT WAS THE NAME AND
ADDRESS OF YOUR EMPLOYER?

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: If you are a patient in a nursing home, please submit a statement from an official of the nursing home that tells us that you are a
patient in the nursing home because of a physical or mental disability. The statement should include the monthly charge you are paying
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,
OR HAVE YOU APPLIED AND NOT RECEIVED A DECISION?
YES

NO

VA FORM 21P-527, XXX 2014

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

APPLIED - NOT RECEIVED DECISION

27D. ARE YOU RECEIVING SOCIAL SECURITY DISABILITY (SSD) OR
SUPPLEMENTAL SOCIAL SECURITY INCOME (SSI) OR HAVE YOU APPLIED
FOR SSD OR SSI BUT NO DECISION HAS BEEN MADE?
YES
NO
APPLIED - NOT RECEIVED DECISION

Page 6

PART Vl - INCOME AND ASSETS
28. DO YOU OR YOUR DEPENDENTS RECEIVE SOCIAL SECURITY BENEFITS?
YES

NO

(If "Yes," complete Items 28A and 28B)
(If "No," skip to Item 29)

A. SOCIAL SECURITY RECIPIENT

B. GROSS MONTHLY AMOUNT
$
$
$
$
$

29. DO YOU OR YOUR DEPENDENTS OWN YOUR/YOUR FAMILY'S PRIMARY RESIDENCE?
YES

NO

(If "No," skip to Item 31A after reading the Important Information below) (If "Yes," complete Items 30A and 30B)

30A. WHAT IS THE SIZE OF THE LOT ON WHICH
THE PRIMARY RESIDENCE SITS?

30B. COULD ANY PART OF THE LOT BE SOLD WITHOUT SELLING THE RESIDENCE?
YES

___________________ Square feet

NO (If "Yes," also complete VA Form 21P-0969, Income and Asset Statement)

IMPORTANT: VA matches income information reported with Federal tax information. Report all income you and your dependents receive on the appropriate sections of this
form and VA Form 21P-0969, Income and Asset Statement, if appropriate.
31A. OTHER THAN SOCIAL SECURITY, DO YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME?
YES

NO

31B. OTHER THAN SOCIAL SECURITY, DID YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME LAST YEAR?
YES

NO

31C. DO YOU OR YOUR DEPENDENTS HAVE MORE THAN $10,000 IN ASSETS? (Note: Assets are all the money and property you or your dependents own. Assets do
not include your/your family's primary residence or personal effects such as appliances and vehicles you or your dependents need for transportation).
YES

NO

31D. IN THE THREE CALENDAR YEARS BEFORE THIS YEAR, DID YOU OR YOUR DEPENDENTS TRANSFER ANY ASSETS? (Examples of asset transfers include giving
them away, selling them, purchasing an annuity, or using them to establish a trust.)
YES

NO

31E. DID YOU ANSWER "YES" TO ANY OF THE ITEMS IN 31A - 31D?
YES

(If "Yes," you must also complete VA Form 21P-0969, Income and Asset Statement)

NO

PART VII - INFORMATION ABOUT YOUR UNREIMBURSED MEDICAL 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 (or expect to pay and continue indefinitely), for
yourself, dependents you are under obligation to support, 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. Do not
include any expenses for which you were reimbursed. If more space is needed, attach a separate VA Form 21P-8416, Medical Expense Report.

IMPORTANT: If you are claiming expenses for in-home care or an assisted living, adult day care, or similar facility, you must complete
the applicable worksheet(s) on pages 10 and 11.
32A. AMOUNT YOU
PAID

32B. DATE
PAID
(Month, year)

32C. HOURLY
32D. PURPOSE
32E. PAID TO
RATE/HOURS (Doctor's fees, hospital charges, attorney (Name of doctor, hospital, pharmacy,
(In-home
attendant only)

fees, etc.)

etc.)

32F. PERSON FOR WHOM
EXPENSE PAID
(Self, spouse, child)

$
$
$
VA FORM 21P-527, XXX 2014

Page 7

PART VII - INFORMATION ABOUT YOUR UNREIMBURSED MEDICAL EXPENSES (Continued)
32A. AMOUNT YOU
PAID

32B. DATE
PAID
(Month, year)

32C. HOURLY
32D. PURPOSE
32E. PAID TO
RATE/HOURS (Doctor's fees, hospital charges, attorney (Name of doctor, hospital, pharmacy,
(In-home
attendant only)

fees, etc.)

etc.)

32F. PERSON FOR WHOM
EXPENSE PAID
(Self, spouse, child)

$
$
$
$
$
$
$
PART VIII - 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

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

VA FORM 21P-527, XXX 2014

Page 8

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

PART X - 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

Page 9

WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY
NOTE: Only complete this worksheet if you are claiming expenses for an assisted living facility, adult day care or similar facility.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder.
INSTRUCTIONS: Use this worksheet if you are claiming a disabled person's care in an assisted living facility, adult day care, or similar facility as unreimbursed
medical expenses. Follow the steps below to determine whether VA may deduct all or some of your out-of-pocket payments to the facility.

STEP 1. Are the expenses you wish to claim due to the disabled person's treatment in a hospital, inpatient treatment center,
nursing home, or VA-approved medical foster home?
YES

NO

(If "NO," continue to Step 2)

(If "YES," claim all payments to the facility qualify as medical expenses in Items 32A - 32F. You are finished completing this worksheet)

STEP 2. Do all of the following apply to the facility?
• The facility is licensed (if the State or country requires it)
• The facility's staff (or the facility's contracted staff) provides the disabled person with
health care or custodial care or both.
• If the facility is residential, it is staffed 24 hours per day with caregivers
NO

YES

(If "NO," payments to the facility do not qualify as medical expenses. You are finished completing this worksheet)

STEP 3. Are you (the veteran) the disabled person?
NO

YES

(If "NO," skip to Step 6)

STEP 4. Did you claim special monthly pension on Page 5, Item 22A of the attached form?
YES

NO

(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amounts you pay the facility for
health care services or assistance with ADLs provided by a health care provider in Items 32A - 32F. Skip to Step 8)

STEP 5. If you answered "YES" in Step 2, you stated that the facility provides you with health care and/or custodial care.
Is this the primary reason you live in the facility (or attend day care in the facility)?
NO (If "YES," all payments to this facility may qualify as medical expenses if VA rates you as eligible for special monthly pension. Please report
separately in Items 32A - 32F applicable amounts you pay the facility for (1) lodging and meals, (2) health care services or assistance with
ADLs provided by a health care provider, and (3) custodial care. Skip to Step 8)

YES

(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Please report separately in Items 32A - 32F
applicable amounts you pay the facility for (1) health care services and assistance with ADLs provided by a health care provider and (2)
custodial care. Skip to Step 8)

STEP 6. Does the disabled person require the health care services or custodial care that the facility provides to him or her because of the disabled
person's mental or physical disability?
YES

NO

(If "YES," you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care services
or custodial care that the facility provides to him or her because of mental or physical disability, and (2) describes the mental or physical
disabilty)
(If "NO," claim payments you pay this facility for health care services or assistance with ADLs provided by a health care provider in
Items 32A - 32F. Skip to Step 8)

STEP 7. If you answered "YES" in Step 2, you stated that the facility provides the disabled person with health care and/or custodial care.
Is this the primary reason the disabled person lives in the facility (or attends day care in the facility)?
(If "YES," claim all payments to this facility (to include meals and lodging) as medical expenses in Items 32A - 32F)
YES

NO

(If "NO," only claim payments you pay the facility for assistance with health care and/or assistance with custodial care as medical
expenses in Items 32A - 32F. Payment to this facility for meals and lodging do not qualify)

STEP 8. Facility Certification: Please submit a current statement showing the fees the claimant pays to your facility and a breakdown of the care received.
I CERTIFY that the information stated within this WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY is accurate and
reflects the current environment pertaining to _______________________________________________________________________________________
(Name of person staying at your facility)

and his or her care at this facility_________________________________________________________________________________________________.
(Name and address of facility)

__________________________________________________________________
(Name, Signature and Title of Person Certifying for the Facility)

VA FORM 21P-527, xxx 2014

___________________
(Date Certified)

Page 10

WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
NOTE: Only complete this worksheet if you are claiming expenses for in-home care.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular • assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder
IMPORTANT: The following activities are examples of Instrumental Activities of Daily Living (IADLs) for VA purposes. VA generally does not recognize assistance
with these activities as medical expenses: (1) Shopping; (2) Food Preparation; (3) Housekeeping; (4) Laundering; (5) Handling medications; (6) Using the telephone;
(7) Transportation (except for medical purposes such as transportation to a doctor's appointment).
INSTRUCTIONS: Use this worksheet if you are claiming payments to a disabled person's in-home attendant as an unreimbursed medical expense.
Follow the steps below to determine whether or not:
• the attendant must be a health care provider for VA purposes and
• VA may deduct payment for assistance with IADLs as well as assistance with ADLs and custodial care

STEP 1. Are you (the veteran) the disabled person?
YES

NO

(If "NO," skip to Step 4)

STEP 2. Did you claim special monthly pension on Page 5, Item 22A of the attached form?
NO

YES

(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately
in Items 32A - 32F applicable amounts you pay an in-home attendant for (1) health care services or assistance with ADLs provided by
a health care provider, and (2) custodial care. Skip to Step 6)

STEP 3. Is the primary responsibility of the in-home attendant to provide you with health care or custodial care?
YES

NO

(If "YES," payments to this in-home attendant may qualify as medical expenses in Items 32A - 32F if VA rates you as eligible for special
monthly pension. Please report separately in Items 32A - 32F amounts you pay an in-home attendant for (1) health care services or
assistance, (2) assistance with IADLs, and (3) custodial care. Skip to Step 6.)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in
Items 32A - 32F applicable amounts you pay an in-house attendant for (1) health care services or assistance with ADLs provided by a
health care provider and (2) custodial care. Skip to Step 6.)

STEP 4. Does the disabled person require the health care services or custodial care that the in-home attendant provides to him or her because of the
disabled person's mental or physical disability?
YES

NO

(If "YES," you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care
services or custodial care that the in-home attendant provides to him or her because of mental or physical disability, and (2) describes
the mental or physical disability)
(If "NO," the attendant must be a health care provider. Only report payments to the in-home attendant for health care services or
assistance with ADLs provided by the health care provider as medical expenses in Items 32A - 32F. Payments for assistance with
IADLs do not qualify as medical expenses). Skip to Step 6

STEP 5. Is the primary responsibility of the in-home attendant to provide the disabled person with health care or custodial care?
YES

NO

(If "YES," payments to the in-home attendant qualify as medical expenses (even assistance with IADLs) and can be reported in
Items 32A - 32F)
(If "NO," report payments to this in-home attendant for health care and/or custodial care as medical expenses in Items 32A - 32F.
Payment for assistance with IADLs do not qualify as a medical expense)

STEP 6. Check all activities below with which the attendant assists the veteran or disabled person with:
ADLs:

EATING

BATHING/SHOWERING

DRESSING

IADLs:

SHOPPING

FOOD PREPARATION

HOUSEKEEPING

USING THE TELEPHONE

TRANSFERRING

USING THE TOILET

LAUNDERING

MANAGING
FINANCES

HANDLING MEDICATIONS

TRANSPORTANTION FOR NON-MEDICAL PURPOSES

STEP 7. In-Home Attendant Certification: Please submit a current breakdown of the time the attendant spends assisting the veteran or disabled person
with health care services, ADLs and IADLs.
I CERTIFY that the information stated within this WORKSHEET FOR IN-HOME ATTENDANT EXPENSES is accurate and
reflects the current environment pertaining to _______________________________________________________________________________________
(Name of Person Requiring Care)

and his or her care from_________________________________________________________________________________________________.
(Name of Attendant)

__________________________________________________________________
(Name, Signature and Title of Certifying Official)

VA FORM 21P-527, xxx 2014

___________________
(Date Certified)

Page 11