Form VA Form 21P-8049 VA Form 21P-8049 Request for Details of Expenses

OMB Approved No. 2900-0138
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

REQUEST FOR DETAILS OF EXPENSES
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 3 before completing the form.
For mail/fax information see Page 3 of the application.
INSTRUCTIONS - We need additional information to determine whether you are entitled to
benefits. Please complete all items. If an answer is "none" or "0" write that. For additional space, use Item
20, "Remarks," or attach a separate sheet indicating the item number to which the answers apply. If you
have any questions or need assistance, please call 1-800-827-1000 (Hearing Impaired TDD line 711).
NOTE: You may either complete the form online or by hand. If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form.

SECTION I: VETERAN'S PERSONAL INFORMATION (MUST COMPLETE)
1. VETERAN'S NAME (Last, first, middle)

2. VETERAN'S SOCIAL SECURITY NUMBER (SSN)

4. VETERAN'S DATE OF BIRTH (MM,DD,YYYY)

3. VA CLAIM NUMBER

Month

Day

Year

SECTION II: CLAIMANT'S PERSONAL INFORMATION (MUST COMPLETE)
5. CLAIMANT'S NAME (Last, first, middle)

7. CLAIMANT'S DATE OF BIRTH (MM,DD,YYYY)

6. CLAIMANT'S SOCIAL SECURITY NUMBER (SSN)

Month

Day

8. CLAIMANT'S RELATIONSHIP TO VETERAN

Year

9. CLAIMANT'S MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code
11. PREFERRED E-MAIL ADDRESS (Optional)

10. TELEPHONE NUMBER(S) (Include Area Code)
Evening

Daytime

SECTION III - DEPENDENTS NOT LIVING WITH YOU
(List ONLY persons you support who DO NOT live with you)
12A. NAME

12B. AGE

12C. RELATIONSHIP

12D. AMOUNT YOU CONTRIBUTE TO SUPPORT
$
$
$
$
$

SECTION IV - DEPENDENTS LIVING WITH YOU
(List ONLY persons you support who DO live with you)
13B. AGE

13A. NAME

VA FORM
XXX XXXX

21P-8049

SUPERSEDES VA FORM 21-8049, SEP 2016,
WHICH WILL NOT BE USED.

13C. RELATIONSHIP

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SECTION V - MONTHLY EXPENSES (EXCEPT MEDICAL)
FOR YOU AND THOSE LISTED IN ITEM 13A AS LIVING WITH YOU
14A. ITEM (Continued)

14B. AMOUNT

14A. ITEM

14B. AMOUNT(Continued)

HOUSING

$

UTILITIES

$

FOOD

$

EDUCATION OF CHILDREN

$

TAXES

$

OTHER
(Specify)

$

INTEREST

$

CLOTHING

$

$
$

SECTION VI - HOSPITAL AND MEDICAL EXPENSES
15A. DO YOU HAVE OR EXPECT TO HAVE ANY LARGE OR UNUSUAL HOSPITAL OR MEDICAL EXPENSES FOR YOURSELF
AND OTHERS YOU SUPPORT AND LIVE WITH?
YES

NO

15B. ESTIMATED COST PER YEAR
$

15C. EXPLANATION

SECTION VII - EDUCATIONAL EXPENSES
16. DO YOU EXPECT TO MAKE PROVISIONS FOR YOUR CHILDREN'S EDUCATIONAL NEEDS, INCLUDING ADVANCED TECHNICAL OR COLLEGE EDUCATION?
YES

NO

SECTION VIII - EXPENSES OF LAST ILLNESS AND BURIAL OF VETERAN, SPOUSE, OR CHILD
AND JUST DEBTS OF DECEASED VETERAN OR PARENT'S SPOUSE

17A. NAME OF DECEASED PERSON (First-middle-last)

17B. RELATIONSHIP TO YOU
SPOUSE

17C. DATE OF DEATH
PARENT

CHILD

EXPENDITURES FOR PERSON NAMED IN ITEM 17A
NOTE - Furnish information concerning unreimbursed expense as follows:

A SPOUSE - For the last illness and burial of veteran's child.

A VETERAN - For his/her spouse's or child's last illness and burial.
A CHILD - For veteran's last illness, burial and just debts.
A PARENT - For his/her spouse's or veteran's last illness and burial
and for his/her spouse's just debts.
18A. NAME AND ADDRESS OF
PERSON TO WHOM PAID

18B. NATURE OF
EXPENSES OR DEBT

A WIDOW(ER) - For veteran's last illness, (paid before or after
the veteran's death), burial and just debts and for the last illness
and burial of veteran's child.
18C. TOTAL AMOUNT
OF EXPENSES OR DEBT

18D. AMOUNT
PAID BY YOU

$

$

$

$

$

$

$

$

18E. DATE
PAID

SECTION IX - COMMERCIAL LIFE INSURANCE PAYMENTS
NOTE: Under Public Law 108-454, VA may not count as income the lump sum proceeds of a life insurance policy on a
veteran who dies after December 9, 2004. Proceeds from all other insurance payments may be countable.
19A.
19B.
19C.

TOTAL RECEIVED OR EXPECTED BY CLAIMANT

AMOUNT
$

EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments, explain payment schedule in

Item 12, Remarks)

NAME OF THE DECEASED FOR WHOM PAYMENT IS RECEIVED.

VA FORM 21P-8049, XXX XXXX

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SECTION X - REMARKS, CERTIFICATION AND SIGNATURE
20. REMARKS

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission or any statement or evidence of a material fact,
knowing it to be false (18 U.S.C. §§ 1001-1002).
I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
21B. DATE SIGNED

21A. SIGNATURE OF CLAIMANT (Do not print, sign in ink)

MAIL TO
Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365

FAX TO
844-655-1604 (Toll Free)

Privacy Act Information: The 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 38, Code of
Federal Regulations 1.576 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, Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. You are required
to respond to obtain or retain benefits. The requested information is considered relevant and necessary to determine entitlement to benefits. The responses you submit are considered
confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies. 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 entitlement to pension or parent's dependency and indemnity compensation (38 U.S.C. 1503 and 1315). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 15 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 1-800-827-1000 to get information on where to send
comments or suggestions about this form.
VA FORM 21P-8049, XXX XXXX

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