VBA-21P-8049 Request for Details of Expenses

OMB Approved No. 2900-0138
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

REQUEST FOR DETAILS OF EXPENSES
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 3 before completing the form.
For mailing 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. VA will interpret a blank space as "NONE" or
"0." For additional space, use Item 23, "Remarks," or attach a separate sheet indicating the item number to
which the answers apply. For additional information or questions contact us online at https://www.va.gov/
contact-us or call us toll-free at 1-800-827-1000 (TTY: 711).

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

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 IDENTIFICATION INFORMATION (MUST COMPLETE)
1. VETERAN'S NAME (First, Middle Initial, Last)

3. VA FILE NUMBER (If applicable)

2. VETERAN'S SOCIAL SECURITY NUMBER

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

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION (MUST COMPLETE)
5. CLAIMANT'S NAME (First, Middle Initial, Last)

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

6. CLAIMANT'S SOCIAL SECURITY NUMBER

8. CLAIMANT'S RELATIONSHIP TO VETERAN
SPOUSE

CHILD

OTHER (Specify)
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

10. TELEPHONE NUMBER (Include Area Code)
Enter International Phone Number (If applicable)
11. E-MAIL ADDRESS (Optional)

SECTION III: DEPENDENTS
12A. NAME

12B. AGE

12C. RELATIONSHIP
SPOUSE

CHILD

OTHER (Specify)
12D. DEPENDENT'S STATUS
LIVES WITH YOU AND RECEIVES YOUR SUPPORT
DOES NOT LIVE WITH YOU AND MONTHLY AMOUNT YOU CONTRIBUTE TO DEPENDENT'S SUPPORT $
13A. NAME

13B. AGE

,

. 00

13C. RELATIONSHIP
SPOUSE

CHILD

OTHER (Specify)
13D. DEPENDENT'S STATUS
LIVES WITH YOU AND RECEIVES YOUR SUPPORT
DOES NOT LIVE WITH YOU AND MONTHLY AMOUNT YOU CONTRIBUTE TO DEPENDENT'S SUPPORT $
VA FORM
XXX XXXX

21P-8049

SUPERSEDES VA FORM 21-8049, JAN 2020.

,

.00
PAGE 1

14A. NAME

14B. AGE

14C. RELATIONSHIP
SPOUSE

CHILD

OTHER (Specify)
14D. DEPENDENT'S STATUS
LIVES WITH YOU AND RECEIVES YOUR SUPPORT

15A. NAME

15B. AGE

.00

,

DOES NOT LIVE WITH YOU AND MONTHLY AMOUNT YOU CONTRIBUTE TO DEPENDENT'S SUPPORT $

15C. RELATIONSHIP
SPOUSE

CHILD

OTHER (Specify)
15D. DEPENDENT'S STATUS
LIVES WITH YOU AND RECEIVES YOUR SUPPORT

16A. NAME

16B. AGE

.00

,

DOES NOT LIVE WITH YOU AND MONTHLY AMOUNT YOU CONTRIBUTE TO DEPENDENT'S SUPPORT $

16C. RELATIONSHIP
SPOUSE

CHILD

OTHER (Specify)
16D. DEPENDENT'S STATUS
LIVES WITH YOU AND RECEIVES YOUR SUPPORT

.00

,

DOES NOT LIVE WITH YOU AND MONTHLY AMOUNT YOU CONTRIBUTE TO DEPENDENT'S SUPPORT $

SECTION IV: MONTHLY EXPENSES (EXCEPT MEDICAL)
FOR YOU AND THOSE LISTED IN SECTION III AS LIVING WITH YOU
ITEM
17A.

HOUSING

17B.

FOOD

17C.

TAXES

17D.

INTEREST

AMOUNT

ITEM (CONTINUED)

$

,

. 00

$

,

. 00

$

,

. 00

$

,

. 00

17E.

CLOTHING

17F.

UTILITIES

17G.

EDUCATION OF CHILDREN

17H.

OTHER (SPECIFY)

AMOUNT (CONTINUED)
$

,

. 00

$

,

. 00

$

,

. 00

$

,

. 00

SECTION V: HOSPITAL AND MEDICAL EXPENSES
18A. 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

18B. ESTIMATED COST PER YEAR
$

NO (If "YES," please complete items 18B and 18C)

. 00

,

18C. EXPLANATION

SECTION VI: EDUCATIONAL EXPENSES
19A. DO YOU EXPECT TO MAKE PROVISIONS FOR YOUR CHILDREN'S EDUCATIONAL NEEDS, INCLUDING ADVANCED
TECHNICAL OR COLLEGE EDUCATION?
YES

NO (If "YES," please complete item 19B and itemize the date(s) and amount(s) of payment(s) in item 23, REMARKS)

19B. TOTAL AMOUNT OF
EDUCATIONAL EXPENSES
PAID BY YOU
$

,

.

00

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

20A. NAME OF DECEASED PERSON (First, Middle Initial, Last)

20B. RELATIONSHIP TO YOU
SPOUSE

20C. DATE OF DEATH (MM/DD/YYYY)

CHILD

PARENT
VA FORM 21P-8049, XXX XXXX

PAGE 2

EXPENDITURES FOR PERSON NAMED IN ITEM 20A
NOTE - Furnish information concerning unreimbursed expenses as follows:
• 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.

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

• LAST ILLNESS - The period from the onset of the acute attack causing death to the date of death (generally within one year of the date of death).
• BURIAL EXPENSES - Include all unreimbursed funeral and burial expenses incident to disposition of the remains of deceased persons under 38 U.S.C. 2302-2303.
• JUST DEBTS - Unsecured debts incurred solely by the Veteran or incurred jointly by the Veteran and surviving spouse, for other than the purpose of real or
personal property. Just debts are paid by a surviving spouse or child after the Veteran's passing.
21A (1). WHOSE EXPENSES WERE PAID? (CHECK ONE)

21A (2). NAME AND ADDRESS OF THE PERSON PAID

DECEASED VETERAN

VETERAN'S DECEASED CHILD

Provider:

DECEASED SPOUSE

DECEASED PARENT OF VETERAN

Address:

21A (3). NATURE OF EXPENSES OR DEBT
LAST ILLNESS

BURIAL

JUST DEBT

OTHER (Specify)

21A (5). TOTAL AMOUNT OF
EXPENSES OR DEBT

21A (4). DATE PAID (MM/DD/YYYY)

$

21B (1). WHOSE EXPENSES WERE PAID? (CHECK ONE)
VETERAN'S DECEASED CHILD

Provider:

DECEASED SPOUSE

DECEASED PARENT OF VETERAN

Address:

LAST ILLNESS

BURIAL

JUST DEBT

OTHER (Specify)

21B (4). DATE PAID (MM/DD/YYYY)

21B (5). TOTAL AMOUNT OF
EXPENSES OR DEBT
$

21C (1). WHOSE EXPENSES WERE PAID? (CHECK ONE)
VETERAN'S DECEASED CHILD

Provider:

DECEASED SPOUSE

DECEASED PARENT OF VETERAN

Address:

LAST ILLNESS

BURIAL

JUST DEBT

OTHER (Specify)

21C (4). DATE PAID (MM/DD/YYYY)

VETERAN'S DECEASED CHILD

Provider:

DECEASED SPOUSE

DECEASED PARENT OF VETERAN

Address:

LAST ILLNESS

BURIAL

JUST DEBT

OTHER (Specify)

21D (4). DATE PAID (MM/DD/YYYY)

,

. 00

.00

,

21C (6). AMOUNT PAID BY YOU
$

,

. 00

21D (2). NAME AND ADDRESS OF THE PERSON PAID

DECEASED VETERAN

21D (3). NATURE OF EXPENSES OR DEBT

21B (6). AMOUNT PAID BY YOU

.00 $

,

21C (5). TOTAL AMOUNT OF
EXPENSES OR DEBT
$

21D (1). WHOSE EXPENSES WERE PAID? (CHECK ONE)

. 00

,

21C (2). NAME AND ADDRESS OF THE PERSON PAID

DECEASED VETERAN

21C (3). NATURE OF EXPENSES OR DEBT

$

21B (2). NAME AND ADDRESS OF THE PERSON PAID

DECEASED VETERAN

21B (3). NATURE OF EXPENSES OR DEBT

.00

,

21A (6). AMOUNT PAID BY YOU

21D (5). TOTAL AMOUNT OF
EXPENSES OR DEBT
$

,

21D (6). AMOUNT PAID BY YOU

.00 $

,

.00

SECTION VIII: 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.
22A.
22B.
22C.

AMOUNT

TOTAL RECEIVED OR EXPECTED BY CLAIMANT

$

,

,

. 00

EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments, explain payment schedule in
Item 23, Remarks)

$

,

,

. 00

NAME OF THE DECEASED FROM WHOM PAYMENT IS RECEIVED.

VA FORM 21P-8049, XXX XXXX

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SECTION IX: REMARKS, CERTIFICATION AND SIGNATURE
23. 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.
24A. SIGNATURE OF CLAIMANT (Do not print, sign in ink)

24B. DATE SIGNED

MAIL TO
Department of Veterans Affairs Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365
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.
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 Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your response is required 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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