Form VA Form 21P-527EZ VA Form 21P-527EZ Application for Veteran's Pension

NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
VETERANS PENSION BENEFITS
(This notice is applicable to veterans claims for: Veterans Pension (a needs based benefit) • Special Monthly Pension •
Benefits Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for veterans pension.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim
processed and there is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans
pension, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for
veterans disability compensation or related compensation benefits, use VA Form 21-526EZ, Application for Disability
Compensation and Related Compensation Benefits. If you are making a claim for survivor benefits, use
VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or Accrued Benefits.
VA forms are available at www.va.gov/vaforms.

FDC Criteria (Claim(s) for Veterans Pension Benefits
1. Submit your claim on a signed and completed VA Form 21P-527EZ, Application for Veterans Pension (attached).
2. Submit simultaneously with your claim:

`

..

All necessary income and asset information; AND
All, if any, relevant, private medical treatment records and an identification of any relevant
treatment records available at a Federal facility, such as a VA medical center.

Note: Read the Important note below and attach current medical evidence showing that you are permanently and totally
disabled, if necessary.
IMPORTANT: If 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. 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.
Special Circumstances

.

Under the special circumstances shown below, you must also submit simultaneously with your claim:
If claiming veterans pension with special monthly pension, a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a nursing home)
a completed VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid
and Attendance;
If claiming a child in school between the ages of 18 and 23, a completed VA Form 21-674, Request for
Approval of School Attendance;
If claiming benefits for a seriously disabled child, all, if any, relevant, private medical treatment
records for the child's pertinent disabilities.

.
.

3. Report for any VA medical examinations VA determines are necessary to decide your claim.

VA FORM
XXX XXXX

21P-527EZ

SUPERSEDES VA FORM 21P-527EZ, OCT 2018,
WHICH WILL NOT BE USED.

Page 1

WHERE TO SEND COMPLETED APPLICATION AND EVIDENCE
When you have completed this application, mail it to the Pension Intake Center listed below. Be sure to attach any
materials that support and explain your claim. Also, make a photocopy of your application and all supporting material you submit to
VA before mailing it.
MAIL: Department of Veterans Affairs
Pension Intake Center
P. O. Box 5365
Janesville, WI 53547-5365
The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!
Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are
entitled. If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your
claim, then VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard
Claim Process. See below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional
Expedited Process). If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim
Process.
WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant
evidence not in your possession.
FDC Program (Optional Expedited Process)
You must:
• Submit your claim in accordance with the
"FDC Criteria" (see page 1)

Standard Claim Process
You must:
• If you know of evidence not in your possession and want
VA to try to get it for you, give VA enough information
about the evidence so that we can request it from the
person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure
we receive all requested records that are not in the possession
of a Federal department or agency.

FDC Program (Optional Expedited Process)
VA will:

Standard Claim Process
VA will:

• Retrieve relevant records from a Federal facility, such as
a VA medical center, that you adequately identify and
authorize VA to obtain

• Retrieve relevant records from a Federal facility such as
a VA medical center, that you adequately identify and
authorize VA to obtain

• Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your
claim

• Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your
claim
• Make every reasonable effort to obtain relevant
records not held by a Federal facility that you adequately
identify and authorize VA to obtain. These may include
records from State or local governments and privately
held evidence and information you tell us about, such as
private doctor or hospital records or records from current
or former employers

VA FORM 21P-527EZ, XXX XXXX

Page 2

WHEN YOU SHOULD SEND WHAT WE NEED
FDC Program (Optional Expedited Process)
You must:

Standard Claim Process
You are strongly encouraged to:
• Send any information or evidence as soon as you can

• Send the information and evidence simultaneously with
your claim
If you submit additional information or evidence after you
submit your "fully developed" claim, then VA will remove the
claim from the FDC Program Expedited Process and process
it in the Standard Claim Process. If we decide your claim before
one year from the date we receive the claim, you will still have
the remainder of the one-year period to submit additional
information or evidence necessary to support the claim.

You have up to one year from the date we receive the claim to
submit the information and evidence necessary to support your
claim. If we decide the claim before one year from the date we
receive the claim, you will still have the remainder of the one
year period to submit additional information or evidence
necessary to support the claim.

WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
If you are claiming...
Veterans Pension (a needs-based benefit)

See the evidence table titled...
Veterans Pension

Special Monthly Pension

Veterans Pension with Special Monthly Pension

Benefits because your child is severely disabled

Child Incapable of self-support

EVIDENCE TABLES
Veterans Pension
To support a claim for veterans pension, the evidence must show:
1. You met certain minimum active service requirements during a period of war.
Generally, those requirements are:
• 90 days of service during a period of war; OR
• 90 days of consecutive service at least one day of which was during a period of war; OR
• 90 days of combined service during more than one period of war:
(Note: If your service began after September 7, 1980, additional length of service requirements may apply, typically
requiring two years of continuous service or completion of active-duty obligation)
• OR, any length of active service during a period of war with a discharge due to a service-connected disability
2. You are age 65 or older or are permanently and totally disabled. Your disability or disabilities do not have to be related
to your military service. You are considered permanently and totally disabled if medical evidence shows you are:
A patient in a nursing home for long-term care or medical foster home; OR
Receiving Social Security disability benefits; OR
Unemployable due to a disability reasonably certain to continue throughout your lifetime; OR
Suffering from a disability that is reasonably certain to continue throughout your lifetime that would make it
impossible for an average person to follow a substantially gainful occupation; OR
• Suffering from a disease or disorder that VA determines causes persons who have that disease or disorder
to be permanently and totally disabled
•
•
•
•

3. Your income and assets are within established limits. You must report income and assets for:
• Yourself
• Your spouse (unless you live apart and you are estranged and you do not contribute to your spouse's support)
• Your child (unless custody has been legally removed by a court and you do not contribute to your child's support
or the child's income is not reasonably available to you).
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.

VA FORM 21P-527EZ, XXX XXXX

Page 3

EVIDENCE TABLES (Continued)
Veterans Pension with Special Monthly Pension
To support a claim for increased pension eligibility based on the need for aid and attendance, the evidence must show:
You have corrected visual acuity of 5/200 or less in both eyes; OR
You have concentric contraction of the visual field to 5 degrees or less; OR
You are a patient in a nursing home due to mental or physical incapacity; OR
You need the aid of another person to perform activities of daily living (ADLs), such as bathing or showering,
dressing, eating, toileting, and transferring (e.g. getting in and out of bed); OR
• You require regular supervision because you are unsafe if you are left alone due to a mental disorder, OR
• You are bedridden, in that your disability requires that you remain in bed apart from any prescribed course
of convalescence or treatment.
•
•
•
•

To support your claim for increased pension eligibility based on being housebound, the evidence must show:
• You have a single permanent disability evaluated as 100 percent disabling; AND due to such disability, you are
permanently and substantially confined to your immediate premises; OR
• You have a single permanent disability evaluated as 100 percent disabled, AND you have an additional disability or
disabilities rated 60 percent or higher.
Child Incapable of Self-Support
To support a claim for benefits based on a veteran's child being incapable of self-support, the evidence must show that the child,
before his or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.

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 recognized marriages is
available at http://www.va.gov/opa/marriage/.

FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations)
contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in
connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered
by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a
claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the
applicable power-of-attorney and the fee agreement requirements.
How VA Determines the Effective Date
If we grant your claim, the beginning date of your entitlement will generally be based on when we received your claim.
Special monthly pension may be assigned for disabilities that affect your ability to perform certain activities of daily living
or the ability to leave your home. Special monthly pension may be effective from the date the medical evidence first shows
entitlement.
For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/.
For more information on VA benefits, visit our web site at www.va.gov, contact us at https://iris.custhelp.va.gov or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the number is 711.
VA forms are available at www.va.gov/vaforms.
IMPORTANT
If you wish to make a claim for veterans disability compensation and/or related compensation benefits, use VA Form 21-526EZ,
Application for Disability Compensation and Related Compensation Benefits. VA forms are available at www.va.gov/vaforms. If you
cannot access this form, write the words "Will claim compensation - send VA Form 21-526EZ" in Item 8 or at the top of the attached
application and VA will send you the form.
VA FORM 21P-527EZ, XXX XXXX

Page 4

OMB Control No. 2900-0002
Respondent Burden: 25 minutes
Expiration Date: XX/XX/XXXX

VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR VETERANS PENSION
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 9 before completing the form.

SECTION I: VETERAN'S PERSONAL INFORMATION (MUST COMPLETE)

1. VETERAN'S NAME (First, Middle Initial, Last)

3. DATE OF BIRTH (MM-DD-YYYY)

2. SOCIAL SECURITY NUMBER

4. HAVE YOU EVER FILED A CLAIM WITH VA?

(If "Yes," provide your file number
in Item 5)

YES
NO
5. VA FILE NUMBER (If applicable)

6A. MAILING ADDRESS
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

6B. TELEPHONE NUMBERS (Include Area Code)
DAYTIME

EVENING

CELL PHONE

7. PREFERRED E-MAIL ADDRESS (If applicable)

8. WHAT DISABILITY(IES) PREVENTS YOU FROM WORKING?
A. DISABILITY(IES)

B. DATE DISABILITY(IES) BEGAN

9. LIST ANY VA MEDICAL CENTERS WHERE YOU RECEIVED TREATMENT FOR YOUR
CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES
A. NAME AND LOCATION OF VA MEDICAL CENTER

B. DATE(S) OF TREATMENT

SECTION II: VETERAN'S SERVICE INFORMATION (MUST COMPLETE)
10A. DID YOU SERVE UNDER ANOTHER NAME?
YES
NO
VA FORM
XXX XXXX

10B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER

(If "Yes," complete Item 10B)
(If "No," skip to Item 11A)

21P-527EZ

SUPERSEDES VA FORM 21P-527EZ, OCT 2018,
WHICH WILL NOT BE USED.

Page 5

SECTION II: VETERAN'S SERVICE INFORMATION (MUST COMPLETE) (CONTINUED)

11A. I ENTERED ACTIVE SERVICE ON (MM-DD-YYYY)

11B. BRANCH OF SERVICE

11C. RELEASE DATE FROM ACTIVE SERVICE (MM-DD-YYYY)

ARMY

NAVY

AIR FORCE

COAST GUARD

MARINE CORPS

11D. SERVICE NUMBER

11E. PLACE OF LAST SEPARATION

12B. DATES OF CONFINEMENT ON (MM-DD-YYYY)

12A. HAVE YOU EVER BEEN A PRISONER OF WAR?
YES
NO

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

From:
To:

SECTION III: VETERAN'S DISABILITY(IES) AND BACKGROUND (MUST COMPLETE)
NOTE: You do not have to submit medical evidence or list disabilities if you are age 65 or older, unless you are housebound, or require the regular assistance of
another person.
13B. WHEN DID THE DISABILITY(IES) BEGIN? (MM-DD-YYYY)

13A. WHAT DISABILITY(IES) PREVENT YOU FROM WORKING?

14A. 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?

(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 complete and signed by a Physician, Physician Assistant (PA), Certified Nurse Practitioner
(CNP), or Clinical Nurse Specialist (CNS.))
14B. ARE YOU NOW OR HAVE YOU RECENTLY BEEN
15A. DATE(S) OF RECENT HOSPITALIZATION OR CARE (MM-DD-YYYY)
YES

NO

HOSPITALIZED OR GIVEN OUTPATIENT OR HOME
CARE DUE TO THE DISABILITY(IES) LISTED IN
ITEM 13A?

YES

NO

15B. NAME AND MAILING ADDRESS OF FACILITY OR DOCTOR

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.
16C. WERE YOU SELF-EMPLOYED BEFORE BECOMING TOTALLY
16A. ARE YOU NOW EMPLOYED?
16B. WHEN DID YOU LAST WORK? (MM-DD-YYYY)
YES

DISABLED?

NO

YES

16D. WHAT KIND OF WORK DID YOU DO?

16E. ARE YOU STILL SELF-EMPLOYED?
YES

NO

(If "Yes," complete Items 16D and 16E)

16F. WHAT KIND OF WORK DO YOU DO NOW?

NO

(If "Yes," complete Item 16F)

17A. ARE YOU NOW IN A NURSING HOME?
YES

17B. WHAT IS THE NAME AND COMPLETE MAILING ADDRESS OF THE FACILITY?

NO

(If "Yes," complete Items 17B and 17C and 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.)
17C. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME COSTS?
YES

NO

(If "No," complete Item 17D)

VA FORM 21P-527EZ, XXX XXXX

17D. HAVE YOU APPLIED FOR MEDICAID?
YES

NO

Page 6

SECTION III: VETERAN'S DISABILITY(IES) AND BACKGROUND (MUST COMPLETE) (CONTINUED)
18A. WHAT WAS THE NAME AND
ADDRESS OF YOUR
EMPLOYER?
18B. WHAT WAS YOUR JOB TITLE?
18C. WHEN DID YOUR JOB BEGIN?

18E. HOW MANY DAYS WERE
LOST DUE TO DISABILITY?

18D. WHEN DID YOUR JOB END?

18F. WHAT WERE YOUR TOTAL
ANNUAL EARNINGS?

$

,

.00

$

,

.00

18A. WHAT WAS THE NAME AND
ADDRESS OF YOUR
EMPLOYER?
18B. WHAT WAS YOUR JOB TITLE?
18C. WHEN DID YOUR JOB BEGIN?

18E. HOW MANY DAYS WERE
LOST DUE TO DISABILITY?

18D. WHEN DID YOUR JOB END?

18F. WHAT WERE YOUR TOTAL
ANNUAL EARNINGS?

SECTION IV: MARITAL STATUS (MUST COMPLETE)
19A. WHAT IS YOUR MARITAL STATUS? (Check one)
MARRIED

DIVORCED

WIDOWED

NEVER MARRIED

(Skip to Section VI if never married)

TELL US ABOUT YOUR MARRIAGE/PREVIOUS MARRIAGES
19B. HOW MANY TIMES HAVE YOU BEEN MARRIED (Including current marriage)?

20A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE (City and State or Country)
20B. TO WHOM MARRIED

(First, Middle, Last Name)

20C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

20D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

20E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED (City and State or Country)
20A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE (City and State or Country)
20B. TO WHOM MARRIED

(First, Middle, Last Name)

20C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

20D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

20E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED (City and State or Country)
20F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 20C, PLEASE EXPLAIN:

VA FORM 21P-527EZ, XXX XXXX

Page 7

SECTION V: CURRENT MARITAL INFORMATION (COMPLETE ONLY IF YOU ARE CURRENTLY MARRIED)
Note - Skip to Section VI if not currently married.
TELL US ABOUT YOUR SPOUSE'S MARRIAGE/PREVIOUS MARRIAGES
21. HOW MANY TIMES HAS YOUR SPOUSE BEEN MARRIED (Including current marriage)?

22A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE (City and State or Country)
22B. TO WHOM MARRIED

(First, Middle, Last Name)

22C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

22D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

22E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED (City and State or Country)

22A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE (City and State or Country)
22B. TO WHOM MARRIED

(First, Middle, Last Name)

22C. TYPE OF MARRIAGE (Ceremonial,

Common-Law, Proxy, Tribal, or Other)

22D. HOW MARRIAGE ENDED (Death, Divorce,

Marriage Has Not Ended)

22E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED (City and State or Country)
22F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22C, PLEASE EXPLAIN:

23A. WHAT IS YOUR SPOUSE'S DATE OF
BIRTH? (MM-DD-YYYY)

23B. WHAT IS YOUR SPOUSE'S SOCIAL
SECURITY NUMBER?

23D. WHAT IS YOUR SPOUSE'S VA FILE
NUMBER (If any)?

23E. DO YOU LIVE WITH YOUR SPOUSE?
YES

NO

23C. IS YOUR SPOUSE ALSO A VETERAN?
YES

NO

(If "Yes," complete Item 23D)

(If "Yes," skip to Section VI)

(If "No," complete Items 23F, 23G and 23H)
23F. WHAT IS YOUR SPOUSE'S 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

23G. TELL US THE REASON YOU ARE NOT LIVING WITH YOUR SPOUSE (i.e.; illness, work, etc.)

23H. HOW MUCH DO YOU CONTRIBUTE MONTHLY
TO YOUR SPOUSE'S SUPPORT?

$

VA FORM 21P-527EZ, XXX XXXX

,

.00

Page 8

SECTION VI: DEPENDENT CHILDREN (COMPLETE IF YOU HAVE DEPENDENT CHILDREN)
Note - Skip to Section VII if you have no dependent children.
24A. NAME OF DEPENDENT CHILD

(First, Middle initial, Last)

24B. DATE AND PLACE OF BIRTH

(City and State or Country)

24C. SOCIAL SECURITY NUMBER
24D. BIOLOGICAL

(Check all that apply)

24E. ADOPTED

24H. SERIOUSLY DISABLED

24F. STEPCHILD

24I. CHILD MARRIED

24G. 18-23 YEARS OLD (in school)

24J. CHILD PREVIOUSLY MARRIED

24A. NAME OF DEPENDENT CHILD

(First, Middle initial, Last)

24B. DATE AND PLACE OF BIRTH

(City and State or Country)

24C. SOCIAL SECURITY NUMBER
24D. BIOLOGICAL

(Check all that apply)

24E. ADOPTED

24H. SERIOUSLY DISABLED

24F. STEPCHILD

24I. CHILD MARRIED

24G. 18-23 YEARS OLD (in school)

24J. CHILD PREVIOUSLY MARRIED

24A. NAME OF DEPENDENT CHILD

(First, Middle initial, Last)

24B. DATE AND PLACE OF BIRTH

(City and State or Country)

24C. SOCIAL SECURITY NUMBER

(Check all that apply)

24D. BIOLOGICAL

24E. ADOPTED

24H. SERIOUSLY DISABLED

24F. STEPCHILD

24I. CHILD MARRIED

24G. 18-23 YEARS OLD (in school)

24J. CHILD PREVIOUSLY MARRIED

Note - In Items 25A through 25D, tell us about the children listed in Item 24A who do not live with you.
25A. NAME OF DEPENDENT CHILD (First, middle initial, last)

25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

25C. NAME OF PERSON THE CHILD LIVES WITH (If applicable) (First, middle initial, last)

25D. MONTHLY AMOUNT YOU CONTRIBUTE TO THE CHILD'S SUPPORT

$

,

.00

25A. NAME OF DEPENDENT CHILD (First, middle initial, last)

25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)
No. &
Street
Apt./Unit Number
State/Province

City
Country

ZIP Code/Postal Code

25C. NAME OF PERSON THE CHILD LIVES WITH (If applicable) (First, middle initial, last)

25D. MONTHLY AMOUNT YOU CONTRIBUTE TO THE CHILD'S SUPPORT
VA FORM 21P-527EZ, XXX XXXX

$

,

.00
Page 9

SECTION VI: DEPENDENT CHILDREN (COMPLETE IF YOU HAVE DEPENDENT CHILDREN) (CONTINUED)
25A. NAME OF DEPENDENT CHILD (First, middle initial, last)

25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

25C. NAME OF PERSON THE CHILD LIVES WITH (If applicable) (First, middle initial, last)

,

$

25D. MONTHLY AMOUNT YOU CONTRIBUTE TO THE CHILD'S SUPPORT

.00

SECTION VII: QUESTIONS REGARDING INCOME AND ASSETS (If you need more space, attach a separate sheet.)
26. DO YOU OR YOUR DEPENDENTS RECEIVE SOCIAL SECURITY BENEFITS?
YES

NO

(If "Yes," complete Items A and B)

(If "No," skip to Item 27)

A. SOCIAL SECURITY RECIPIENT (First, middle initial, last)

B. GROSS MONTHLY AMOUNT

$

,

.00

$

,

.00

$

,

.00

$

,

.00

$

,

.00

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

NO

(If "Yes," complete Items 28A and 28B)

(If "No," skip to Item 29A)

28A. IS THE SIZE OF THE LOT ON WHICH THE PRIMARY
RESIDENCE SITS, OVER 2 ACRES (87,120 SQ FT)?
YES

NO

(If yes, complete 28B and 28C, if no, skip to
29A.)

28B. IF PRIMARY RESIDENCE SITS ON A LOT OVER 2 ACRES (87,120 SQ FT), WHAT IS
THE VALUE OF LAND OVER 2 ACRES?

$

,

.00

(Do not include the value of the residence or the first
2 acres.)

28C. IS THE LAND OVER 2 ACRES (87,120 SQ FT) LISTED IN 28B MARKETABLE?
YES

NO

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.
29A. OTHER THAN SOCIAL SECURITY, DO YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME?
YES

NO

29B. OTHER THAN SOCIAL SECURITY, DID YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME LAST YEAR?
YES

NO

29C. 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

29D. 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

29E. DID YOU ANSWER "YES" TO ANY OF THE ITEMS IN 29A - 29D?
YES

NO

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

VA FORM 21P-527EZ, XXX XXXX

Page 10

SECTION VIII: INFORMATION ABOUT YOUR UNREIMBURSED MEDICAL EXPENSES
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 or your dependents
were/will be reimbursed. Please make sure to complete all 6 criteria below (if applicable). If more space is needed, complete and attach a separate
VA Form 21P-8416, Medical Expense Report.
IMPORTANT: If you are claiming expenses for in-home care or assisted living, adult day care, or similar facility, you must complete the applicable
worksheet(s) on pages 10 and 11.
30. ARE YOU OR YOUR DEPENDENTS CLAIMING UNREIMBURSED MEDICAL EXPENSES?
YES

NO

(If "No," skip to Section IX)

A. WHOSE MEDICAL, LEGAL, OR
OTHER EXPENSES WERE PAID?

B. PAID TO

(Name of Provider,
Insurance company,
Nursing home, etc.)

C. PURPOSE

(Medicare premiums,
Nursing Home,etc.)

D. DATE PAID

(MM-DD-YYYY)

E. HOURLY RATE/
HOURS (In-home

Provider Only)

F. AMOUNT YOU
PAY

$

.00 $

.00

$

.00 $

.00

$

.00 $

.00

$

.00 $

.00

$

.00 $

.00

$

.00, $

.00

$

.00 $

.00

$

.00 $

.00

$

.00 $

.00

$

.00 $

.00

SECTION IX: DIRECT DEPOSIT INFORMATION (MUST COMPLETE)
The Department of Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in
direct deposit, please attach a voided personal check, deposit slip, or provide the information requested below in Items 31, 32, and 33. If you do not have
a bank account, please visit https://www.benefits.va.gov/benefits/banking.asp. This website provides information about the Veterans Benefits Banking
Program (VBBP), and a link to banks and credit unions that may fit your needs. You may also call 1-800-827-1000. 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.
31. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA.)
CHECKING

SAVINGS

Account No.:
32. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank
where you want your direct deposit)

VA FORM 21P-527EZ, XXX XXXX

I CERTIFY THAT I DO NOT
HAVE AN ACCOUNT WITH A
FINANCIAL INSTITUTION OR
CERTIFIED PAYMENT AGENT
33. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the bottom
left of your check)

Page 11

SECTION X: CLAIM CERTIFICATION AND SIGNATURE (MUST COMPLETE)
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 and I waive any privilege which makes the information confidential.
I certify I have received the notice attached to this application titled Notice to Veteran of Evidence Necessary to Substantiate a Claim for
Veterans Non-Service Connected Pension Benefits.
I certify I have enclosed all the information or evidence that will support my claim, to include an identification of relevant records available at a Federal
facility, such as a VA medical center; OR, I have no information or evidence to give VA to support my claim; OR, I have checked the box in Item 34,
indicating that I do not want my claim considered for rapid processing in the Fully Developed Claim (FDC) Program because I plan to submit further
evidence in support of my claim.
34. The FDC Program is designed to rapidly process compensation or pension claims received with the evidence necessary to decide the claim. VA will
automatically consider a claim submitted on this form for rapid processing under the FDC Program. Check the below box ONLY if you DO NOT
want your claim considered for rapid processing under the FDC Program because you plan to submit further evidence in support of your claim.
I DO NOT want my claim considered for paid processing under the FDC Program because I plan to submit further evidence in support of my claim.
35A. PRINTED NAME

35B. VETERAN'S SIGNATURE (REQUIRED)

35C. DATE SIGNED (MM-DD-YYYY)

SECTION XI: WITNESSES TO SIGNATURE (MUST COMPLETE ONLY IF VETERAN SIGNED ITEM 35A WITH AN "X")
36A. SIGNATURE OF WITNESS (If veteran signed above using an "X")

37A. SIGNATURE OF WITNESS (If veteran signed above using an "X")

36B. PRINTED NAME AND ADDRESS OF WITNESS

37B. PRINTED NAME AND ADDRESS OF WITNESS

Name:

Name:

Address:

Address:

PRIVACY ACT NOTICE: 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 25 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-527EZ, XXX XXXX

Page 12

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," all payments to the facility qualify as medical expenses in Items 30A - 30F. 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
YES

NO

(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?
YES

NO

(If "NO," skip to Step 6)

STEP 4. Did you claim special monthly pension on Page 5, Item 14A 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 30A - 30F. 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)?
YES

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 30A - 30F 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)

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 disability)
(If "NO," claim payments you pay this facility for health care services or assistance with ADLs provided by a health care provider in Items 30A
- 30F. 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)?
YES

NO

(If "YES," claim all payments to this facility (to include meals and lodging) as medical expenses in Items 30A - 30F)
(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 30A - 30F. 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 Facility)

and his or her care at this facility
(Name of Facility)

at
(Address of Facility (Line 1))

(Address of Facility (Line 2))

(Name of Person Certifying for the Facility)
(Signature of Person Certifying for the Facility)

(Title of Person Certifying for the Facility)

VA FORM 21P-527EZ, XXX XXXX

(Date Certified)

Page 13

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 14A of the attached form?
YES

NO

(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in Items 30A 30F 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 30A - 30F if VA rates you as eligible for special monthly
pension. Please report separately in Item 30A - 30F amounts you pay an in-home attendant for (1) health-care services or assistance with ADLs
provided by a health care provider, (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 30A 30F 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 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 30A - 30F. 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 30A - 30F.)
(If "NO," report payments to this in-home attendant for health care and/or custodial care as medical expenses in Items 30A - 30F. 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

IADLs:

SHOPPING

BATHING/SHOWERING
FOOD PREPARATION

HANDLING MEDICATIONS

DRESSING

TRANSFERRING

HOUSEKEEPING

USING THE TELEPHONE

LAUNDERING

USING THE TOILET
MANAGING FINANCES

TRANSPORTATION 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 of Certifying Official)
(Signature of Certifying Official)

(Title of Certifying Official)

VA FORM 21P-527EZ, XXX XXXX

(Date Certified)

Page 14