Form 21P-0969 Income and Asset Statement in Support of Claim for Pensi

INCOME AND ASSET STATEMENT IN SUPPORT OF CLAIM FOR PENSION OR
PARENT'S DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
(Attachment to VA Forms 21P-527, 21P-527EZ, 21P-534, and 21P-534EZ)
IMPORTANT: This is not a stand-alone form. Only complete this attachment if you are directed to do so when you complete one of the following:
(1) Section VI on VA Form 21P-527 or Section VIII on VA Form 21P-527EZ.
(2) Section VII on VA Form 21P-534 or Section VIII on VA Form 21P-534EZ.
VETERAN/CLAIMANT PERSONAL INFORMATION
1. VETERAN'S NAME (Last, First, Middle)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VETERAN'S FILE NUMBER (If known)

4. CLAIMANT'S NAME (Last, First, Middle)

5. CLAIMANT'S SOCIAL SECURITY NUMBER

6. CLAIMANT'S TELEPHONE NUMBER

7. TYPE OF CLAIMANT (Check only one box)
VETERAN

SURVIVING SPOUSE

SURVIVING CHILD

PARENT

IMPORTANT INFORMATION FOR CLAIMANTS
NOTE - The term "assets" means the fair market value of all property that an individual owns, including all real and personal property(excluding
the value of your or your dependent's 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.
If you are a Veteran, 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 or children (unless you do not have custody* and you do not contribute to your child's or children's support)
If you are a Surviving Spouse, you must report income and assets for:
• yourself
• any child of the veteran who is in your custody*
If you are a Surviving Child or the Custodian of a Surviving Child, you must report income and assets for the:
• child
• child's custodian (unless the child's custodian is an institution)
• custodian's spouse
If you are a Parent, you must report income** for:
• yourself
• your spouse (even if your spouse is the veteran's other parent. If your spouse is the veteran's other parent, you
must both file claims)
*Child custody for pension purposes is defined in 38 C.F.R. § 3.57(d). A natural or adoptive parent has custody of a child unless custody is
legally removed. For pension purposes, a child who has attained age 18 remains in the custody of the person who had custody before the child
turned age 18 unless custody is legally removed.
** Parent's DIC claimants do not need to report or provide documentation of their assets.
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 VAaccredited 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.
NOTICE
IMPORTANT: VA will compare the information you report on this form to Internal Revenue Service (IRS) and Social Security Administration (SSA)
records to verify your income for the past three tax years for which information is available. Information from the IRS or SSA that conflicts with the
income information you provide with your application may delay your claim and/or reduce your benefit amount.
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 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, 58VA21/22/28, Compensation, Pension, Education, Vocational Rehabilitation and Employment Records - VA,
published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is considered relevant and necessary to determine
maximum benefits provided under the law. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not
deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in
effect. 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.
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-0969, XXXX

Page 1

OMB Control No. 2900-0829
Respondent Burden: 25 minutes
Expiration Date: XXXXXXX

INCOME AND ASSET STATEMENT IN SUPPORT OF CLAIM FOR PENSION OR
PARENTS' DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
(Attachment to VA Forms 21P- 527, 21P-527EZ, 21P-534, and 21P-534EZ)
SECTION I: RETIREMENT INCOME AND DISTRIBUTIONS (If additional space is needed attach a separate sheet)
1. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE ANY INCOME IN THE NEXT 12 MONTHS INCLUDING,
BUT NOT LIMITED TO, DISTRIBUTIONS FROM A RETIREMENT PLAN, SUCH AS:
• Military Retirement
• Civil Service Retirement
• IRA
• SEP
• Qualified Plans
• Pensions
• Annuities
• Black Lung
NO (If "No," skip to Section II)
YES

A. INCOME RECIPIENT
(Veteran, Spouse, Child,
Parent, Custodian, etc.)

B. WHO IS THE INCOME PAYER?
(Name of business, financial
institution, etc.)

C. WHAT IS YOUR CURRENT
AND/OR EXPECTED INCOME?
(Provide documentation of current income and
expected income changes)

CURRENT MONTHLY
GROSS INCOME

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

CURRENT MONTHLY
GROSS INCOME

YES

$

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

YES

$

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

YES

$

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

21P-0969

NO

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?

VA FORM
XXXX

NO

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?

CURRENT MONTHLY
GROSS INCOME

NO

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?

CURRENT MONTHLY
GROSS INCOME

D. WHAT IS THE TOTAL
CASH VALUE OF THE
ASSET
ASSOCIATED WITH
THIS INCOME?
(Provide documentation of
assets)

YES

NO

$
Page 2

SECTION II - UNEMPLOYMENT INCOME (If additional space is needed attach a separate sheet)
2. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE UNEMPLOYMENT INCOME IN THE NEXT 12 MONTHS?
YES

NO

(If "No," skip to Section III)

A. INCOME RECIPIENT

(Veteran, Spouse, Child, Parent, Custodian, etc.)

B. WHAT IS YOUR OR YOUR DEPENDENTS CURRENT
AND/OR EXPECTED UNEMPLOYMENT INCOME?
(Provide documentation of current income and
expected income changes)

CURRENT MONTHLY
GROSS INCOME

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
CURRENT MONTHLY
GROSS INCOME

$

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?

$

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?

$

$

DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

VA FORM 21P-0969, XXXX

NO

YES

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

CURRENT MONTHLY
GROSS INCOME

NO

YES

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
CURRENT MONTHLY
GROSS INCOME

NO

YES

NO

YES

$

Page 3

SECTION III - SAVINGS BONDS (If additional space is needed attach a separate sheet)
3. DO YOU OR YOUR DEPENDENTS OWN A SAVINGS BOND OR RECEIVE OR EXPECT TO RECEIVE INTEREST FROM A SAVINGS BOND WITHIN
THE NEXT 12 MONTHS?
YES

NO

(If "No," skip to Section IV)

A. WHO OWNS THE SAVINGS BOND?
(Veteran, Spouse, Child, Parent,
Custodian, etc.)

WHAT IS THE GROSS ANNUAL
INCOME?

$

DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

YES

NO

YES

NO

$

$

$

WHAT IS THE GROSS ANNUAL
INCOME?

$

DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

$

$

$

DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

NO

$

DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?

WHAT IS THE GROSS ANNUAL
INCOME?

YES

$

WHAT IS THE GROSS ANNUAL
INCOME?

VA FORM 21P-0969, XXXX

C. WHAT IS THE CURRENT
FACE VALUE
OF THE
SAVINGS BOND?

B. WHAT IS YOUR OR YOUR DEPENDENTS CURRENT AND/OR
EXPECTED ANNUAL INCOME (interest earned)?
(Attach a copy of the savings bond)

YES

NO

$

$

Page 4

SECTION IV - RENTAL PROPERTY, FARM OR BUSINESS INCOME (If additional space is needed attach a separate sheet)
4. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE, INCOME FROM RENTAL PROPERTY, FARM OR BUSINESS WITHIN THE NEXT
12 MONTHS?

YES

NO (If "No," skip to Section V)

A. INCOME RECIPIENT
(Veteran, Spouse, Child,
Parent,
Custodian, etc.)

B. WHAT IS YOUR OR YOUR
DEPENEDENTS CURRENT OR
EXPECTED INCOME
FROM THIS SOURCE?
(Provide documentation of current income
and
expected income changes)

CURRENT MONTHLY
$
GROSS INCOME
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
YES

NO

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

C. WHAT KIND OF INCOME
IS THIS?
(Check applicable box)

D. WHAT IS THE VALUE OF YOUR
PORTION OF THE PROPERTY, FARM,
OR BUSINESS?
(Note: Subtract the amount of Mortgages or
other encumbrances specific to the property.
Provide available documentation)

Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed
VA Form 21P-4185 with this application
Business - Submit a completed

VA Form 21P-4185 with this application

$

CURRENT MONTHLY
$
GROSS INCOME
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
YES

NO

Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed
VA Form 21P-4185 with this application
Business - Submit a completed

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

VA Form 21P-4185 with this application

$

CURRENT MONTHLY
$
GROSS INCOME
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
YES

NO

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed
VA Form 21P-4185 with this application
Business - Submit a completed

VA Form 21P-4185 with this application

$

CURRENT MONTHLY
$
GROSS INCOME
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
YES

Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed

NO

VA Form 21P-4185 with this application

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT

Business - Submit a completed

VA Form 21P-4185 with this application

$

VA FORM 21P-0969, XXXX

Page 5

SECTION V - INTEREST, ROYALTIES, AND DIVIDENDS (If additional space is needed attach a separate sheet)
5. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE, INTEREST, DIVIDENDS, OR ROYALTIES WITHIN THE NEXT 12 MONTHS?
YES

NO (If "No," skip to Section VI)

IMPORTANT: Do not report income you have already reported in Section III (Savings Bonds) or Section IV (Rental Property, Farm or Business Income).

A. INCOME RECIPIENT
(Veteran, Spouse, Child,
Parent, Custodian, etc.)

B. WHO IS THE INCOME PAYER?
(Name of business,
financial institution, etc.)

C. WHAT IS YOUR OR YOUR DEPENDENTS D. WHAT IS THE TOTAL CASH
VALUE OF THE ASSET
CURRENT AND/OR EXPECTED INCOME?
ASSOCIATED WITH THIS
(Provide documentation of current income and
INCOME?
expected income changes)
(Provide documentation of
assets)
CURRENT MONTHLY
GROSS INCOME

$

DO YOU EXPECT THIS INCOME TO CHANGE IN
THE NEXT 12 MONTHS?
YES

NO

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$

CURRENT MONTHLY
GROSS INCOME

$

DO YOU EXPECT THIS INCOME TO CHANGE IN
THE NEXT 12 MONTHS?
YES

NO

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$

CURRENT MONTHLY
GROSS INCOME

$

DO YOU EXPECT THIS INCOME TO CHANGE IN
THE NEXT 12 MONTHS?
YES

NO

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$

CURRENT MONTHLY
GROSS INCOME

$

DO YOU EXPECT THIS INCOME TO CHANGE IN
THE NEXT 12 MONTHS?
YES

NO

DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$

VA FORM 21P-0969, XXXX

Page 6

SECTION VI - WAGES - INCLUDING SELF-EMPLOYMENT (If additional space is needed attach a separate sheet)
6. ARE YOU OR YOUR DEPENDENTS RECEIVING WAGES OR EXPECTING TO RECEIVE WAGES WITHIN THE NEXT 12 MONTHS?

YES

NO (If "No," skip to Section VII)

A. WAGE RECIPIENT
(Veteran, Spouse, Child, Parent,
Custodian, etc.)

B. WHAT ARE YOUR OR YOUR DEPENDENTS CURRENT WAGES
AND/OR EXPECTED WAGES?
(Provide documentation of current wages and expected wage changes)

CURRENT MONTHLY
GROSS WAGE

$

DO YOU EXPECT THIS WAGE INCOME TO CHANGE IN THE
NEXT 12 MONTHS?
YES

NO
DATE WAGE INCOME
WILL CHANGE AND EXPECTED
WAGE AMOUNT
$

CURRENT MONTHLY
GROSS WAGE

$

DO YOU EXPECT THIS WAGE INCOME TO CHANGE IN THE
NEXT 12 MONTHS?
YES

NO
DATE WAGE INCOME
WILL CHANGE AND EXPECTED
WAGE AMOUNT
$

CURRENT MONTHLY
GROSS WAGE

$

DO YOU EXPECT THIS WAGE INCOME TO CHANGE IN THE
NEXT 12 MONTHS?
YES

NO
DATE WAGE INCOME
WILL CHANGE AND EXPECTED
WAGE AMOUNT
$

CURRENT MONTHLY
GROSS WAGE

$

DO YOU EXPECT THIS WAGE INCOME TO CHANGE IN THE
NEXT 12 MONTHS?
YES

NO
DATE WAGE
WILL CHANGE AND EXPECTED
WAGE AMOUNT
$

VA FORM 21P-0969, XXXX

Page 7

SECTION VII - DISCONTINUED INCOME IN THE PRIOR TAX YEAR (If additional space is needed attach a separate sheet)
7. DID YOU OR YOUR DEPENDENTS RECEIVE INCOME LAST YEAR THAT IS NO LONGER BEING RECEIVED OR WAS A ONE-TIME PAYMENT?
YES

NO (If "No," skip to Section VIII)

A. INCOME RECIPIENT
(Veteran, Spouse, Child, Parent, Custodian, etc.)

B. WHO WAS THE INCOME PAYER?
(Name of business, financial institution, etc.)

C. WHAT WAS THE GROSS
ANNUAL AMOUNT
REPORTED TO THE IRS?

D. WHEN DID THE
INCOME STOP?
(MM,DD,YYYY)

$

$

$

$

VA FORM 21P-0969, XXXX

Page 8

NOTE: Parent's DIC Claimants Only - You do not have to complete Sections VIII thru XI. Return to the application form. Your certification,
signature and date on the application form applies to this attachment.
Pension Claimants - Continue to complete the attachment.

SECTION VIII - ASSETS PREVIOUSLY NOT REPORTED (If additional space is needed attach a separate sheet)
8. DO YOU OR YOUR DEPENDENTS HAVE ASSETS NOT ALREADY REPORTED, SUCH AS NON-INTEREST-BEARING ACCOUNTS, CASH, STOCKS,
BONDS, OR REAL ESTATE?
YES
NO (If "No," skip to Section IX)

B. WHAT IS THE CURRENT CASH VALUE
OF THE ASSET?
(Provide a bank or other official statement showing
the current value. Do not report assets you have already
reported in Sections I through VII)

A. ASSET OWNER
(Veteran, Spouse, Child, Parent,
Custodial, etc.)

C. AMOUNT OWED ON THE ASSET OR
AMOUNT MORTGAGED OR OTHERWISE
ENCUMBERED?
(Provide documentation of mortgages or other
encumbrances)

$

$

$

$

$

$

$

$

SECTION IX - ASSET TRANSFERS (If additional space is needed attach a separate sheet)
9. IN THE CURRENT YEAR AND/OR PRIOR 3 TAX YEARS, DID YOU OR YOUR DEPENDENTS SELL, CONVEY, TRADE, OR GIVE AWAY ASSETS?
YES

NO

(If "No," skip to Section X)

A. WHO OWNED THE ASSET?
(Veteran, Spouse, Child, Parent,
Custodian, etc.)

B. HOW WAS THE
ASSET TRANSFERRED?

SOLD

C. WHO DID YOU
TRANSFER
THE ASSET TO?

Name:

CONVEYED
GAVE AWAY

_____________________

TRADED
OTHER (Explain below)

Name:

CONVEYED
GAVE AWAY

_____________________

TRADED
OTHER (Explain below)

Was the asset transferred for less than fair market value?
Yes

No

Was an asset reported to the IRS sold?
Yes
No
What was the original purchase price?_____________________

Relationship:
_____________________

SOLD

D. DETAILS OF THE ASSET TRANSFER

(Provide documentation of the transfer. A transfer for less than fair
market value means you disposed of an asset for less than the asset
was worth)

What was the sale price?_____________________
What date was the asset sold?
(MM,DD,YYYY)_______________
What was the gain (capital gain, etc.)?_____________________
Was the asset transferred for less than fair market value?
Yes
No
Was an asset reported to the IRS sold?
Yes
No
What was the original purchase price?_____________________

Relationship:
_____________________

What was the sale price?_____________________
What date was the asset sold?
(MM,DD,YYYY)_______________
What was the gain (capital gain, etc.)?_____________________

VA FORM 21P-0969, XXXX

Page 9

SECTION IX: ASSET TRANSFERS (Continued)
A. WHO OWNED THE ASSET?
(Veteran, Spouse, Child,
Parent, Custodian, etc.)

B. HOW WAS THE
ASSET TRANSFERRED?

C. WHO DID YOU
TRANSFER
THE ASSET TO?

SOLD
Name:

CONVEYED
GAVE AWAY

_____________________

TRADED

D. DETAILS OF THE ASSET TRANSFER

(Provide documentation of the transfer. A transfer for less than fair
market value means you disposed of an asset for less than the asset
was worth)
Was the asset transferred for less than fair market value?
Yes
No
Was an asset that was reported to the IRS sold?
Yes
No
What was the original purchase price?_____________________

OTHER (Explain below)

Relationship:
_____________________

What was the sale price?_____________________
What date was the asset sold?
(MM,DD,YYYY)_______________
What was the gain (capital gain, etc.)?_____________________

SOLD

Name:

CONVEYED
_____________________

GAVE AWAY
TRADED

Was the asset transferred for less than fair market value?
Yes
No
Was an asset that was reported to the IRS sold?
Yes
No
What was the original purchase price?_____________________

OTHER (Explain below)

Relationship:
_____________________

What was the sale price?_____________________
What date was the asset sold?
(MM,DD,YYYY)_______________
What was the gain (capital gain, etc.)?_____________________

SECTION X: ANNUITIES AND TRUSTS (Attach a separate sheet if more than one annuity or trust is involved)
10A. IN THE CURRENT YEAR OR THE PRIOR THREE TAX YEARS, DID YOU OR YOUR DEPENDENTS TRANSFER ANY ASSETS TO A TRUST OR PURCHASE
AN ANNUITY?
Yes

No

(If "No," skip to Section XI)

10B. WHAT WAS THE MARKET VALUE OF THE ASSET AT THE TIME OF TRANSFER OR ANNUITY PURCHASE?
10C. WHAT WAS THE DATE THE ASSET WAS TRANSFERRED?
(MM,DD,YYYY)
10D. DID YOU PURCHASE AN ANNUITY WITH THE ASSETS? 10E. PROVIDE DATE OF PURCHASE
Yes

No

$

10F. PROVIDE NAME OF PERSON THE ASSET WAS
PURCHASED FROM (First-Middle-Last)

(If "Yes," complete Items 10E through 10G)

10G. PROVIDE TYPE OF ANNUITY PURCHASED (Give details and attach documentation)

10H. WERE THE ASSETS USED TO ESTABLISH A TRUST?

Yes

No

10I. PROVIDE TAX NUMBER

10J. PROVIDE DETAILS AND ATTACH DOCUMENTATION

(If "Yes," complete Items 10I through 10J)

10K. WAS THE TRUST ESTABLISHED FOR A CHILD OF THE VETERAN WHO WAS INCAPABLE OF SELF-SUPPORT PRIOR TO REACHING AGE 18?
Yes
No
VA FORM 21P-0969, XXXX

Page 10

SECTION XI - WAIVER OF RECEIPT OF INCOME (If additional space is needed attach a separate sheet)
11. DID YOU OR YOUR DEPENDENTS WAIVE OR EXPECT TO WAIVE ANY RECEIPT OF INCOME IN THE NEXT 12 MONTHS?
YES

NO

(If "NO," skip this section. This attachment is complete. Return to the application. Your certification, signature and date on the application
form applies to this attachment)

B. WHAT IS YOUR OR YOUR DEPENDENTS CURRENT
AND/OR EXPECTED WAIVED INCOME?
(Provide documentation of income and
expected income changes)

A. INCOME RECIPIENT
(Veteran, Spouse, Child, Parent, Custodian, etc.)

CURRENT MONTHLY
GROSS WAIVED
INCOME

$

DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
YES

NO
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
$

CURRENT MONTHLY
GROSS WAIVED
INCOME

$

DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
YES

NO
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
$

CURRENT MONTHLY
GROSS WAIVED
INCOME

$

DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
YES

NO
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
$

CURRENT MONTHLY
GROSS WAIVED
INCOME

$

DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
YES

NO
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
$

THIS ATTACHMENT FORM IS COMPLETE. RETURN TO THE APPLICATION FORM. YOUR CERTIFICATION, SIGNATURE AND DATE
ON THE APPLICATION FORM APPLIES TO THIS ATTACHMENT.
VA FORM 21P-0969, XXXX

Page 11