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 (D.I.C.)

This form should be used to report or verify income and/or net worth. Changes to income and net worth over multiple years must be
reported on a separate VA Form 21P-0969 for each year. Changes to dependents and medical expenses may impact your benefits.
Submit the following forms if you need to update dependent or medical expense information.
• To update dependents, submit VA Form 21-686c, Application Request to Add and/or Remove Dependents.
• To update medical expenses, submit VA Form 21P-8416, Medical Expense Report.
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 dependents' primary residence including the residential lot area, not to exceed 2 acres); less the
amount of mortgages or other (specify) encumbrances specific to the mortgages or encumbered property. Personal property means the
value of personal effects that are in excess of being suitable consistent with a reasonable mode of life. There is a space on your initial
application form to provide the value of the portion of your primary residence that exceeds 2 acres.
If you are a Veteran, you must report 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)
• Any constructive member of the household.***
If you are a Surviving Spouse, you must report income and assets for:
• Yourself
• Your child or children (unless you do not have custody,* and you do not contribute to your child's or children's support)
• Any constructive member of the household.***
If you are a Surviving Child or the Custodian of a Surviving Child, you must report income and assets for:
• Yourself and/or the surviving child
• Child's custodian (unless the child's custodian is an institution)
• Custodian's spouse
• Any constructive member of the household.***
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 should file
separate claims.)
• Any constructive member of the household.***
* 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 18 unless custody is legally removed.
** Parents' D.I.C. claimants do not need to report or provide documentation of their assets.
***Constructive member means the income and assets can be for any relative of the claimant (not necessarily a dependent for VA
purposes), spouse in a nursing home, a child away at school, or similar situation.

THIS FORM IS COMPRISED OF 14 SECTIONS.
BE SURE TO ANSWER THE QUESTION(S) IN EACH SECTION AS REQUIRED.
SECTION I: VETERAN'S IDENTIFICATION INFORMATION
SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION
SECTION III: RECURRING INCOME NOT ASSOCIATED WITH ACCOUNTS OR
ASSETS
SECTION IV: INCOME AND NET WORTH ASSOCIATED WITH FINANCIAL
ACCOUNTS
SECTION V: INCOMENT AND NETE WORTH ASSOCIATED WITH OWNED
ASSETS
SECTION VI: INCOME AND NET WORTH ASSOCIATED WITH ROYALTIES AND
OTHER PROPERTIES
SECTION VII: ASSET TRANSFERS
VA FORM 21P-0969, XXXX

SECTION VIII: TRUSTS
SECTION IX: ANNUITIES
SECTION X: ASSETS PREVIOUSLY NOT
REPRTED
SECTION XI: DISCONTINUED OR IRREGULAR
INCOME
SECTION XII: WAIVER OF RECEIPT INCOME
SECTION XIII: CERTIFICATION AND
SIGNATURE
SECTION XIV: WITNESS TO SIGNATURE
Page 1

INSTRUCTIONS FOR INDIVIDUAL SECTIONS
SECTION III: RECURRING INCOME NOT ASSOCIATED WITH ACCOUNTS OR ASSETS
This section is for reporting all income not attached to a physical asset, financial account or other type of net worth. Income generated from
assets will be captured in other sections of this form. Examples of income not associated with accounts or assets may include:
• Pensions
• Railroad Retirement Benefits
• Social Security Income
• Wages
• Civil Service Retirement
• Military Retirement
• Unemployment Benefits
• Black Lung Benefits
• Private Retirement
NOTE: If submitting this form with an initial application, do not report income(s) previously reported on your application (VA Form 21P-527EZ or
VA Form 21P-534EZ.)
SECTION IV: INCOME AND NET WORTH ASSOCIATED WITH FINANCIAL ACCOUNTS
This section is for reporting assets not related to property that generates income. Examples of income and net worth associated with accounts
may include:
• Savings Bonds
• Stocks and Dividends
• Annuities

• Interest Earning Accounts (Checking, Savings, etc.)
• Individual Retirement Account (IRA) Distributions (Including RMDs)
• Pension Plans with Cash Value (Employee, SEP, etc.)

SECTION V: INCOME AND NET WORTH ASSOCIATED WITH OWNED ASSETS
This section is for reporting physical assets that generate income. These assets may be partially owned by third parties. Only report the
portion of the asset that you own. When reporting the asset value of your portion of the property within this section, you may subtract from
the reported value any mortgage or other encumbrance that you still owe for each, if applicable. Examples of current income and net worth
associated with owned assets may include:
• Rental Property
• Farm Earnings
• Business Earnings
Additional documentation may be required for each of the following income sources:
• Property assets may require submission of a statement showing the fair market value (not an evaluation for property taxes, as appraisal from
a licensed appraiser, realtor, or an established online estimation tool is preferred).
• If you are in receipt of income from a:
o
Farm - You must submit VA Form 21P-4165, Pension Claim Questionnaire for Farm Income.
o
Business or a rental property - You must submit VA Form 21P-4185, Report of Income from Property or Business.
SECTION VI: INCOME AND NET WORTH ASSOCIATED WITH ROYALTIES AND OTHER PROPERTIES
This section is for reporting income generated from royalties and other owned assets. For these types of assets, you may submit any
documentation you have deomonstrating the sellability, value and income of the asset. Examples of income generated from royalties and other
properties include:
• Intellectual Property Royalties (i.e., Acting, Written Works, Invention)
• Mineral Royalties
• Other Land Use
SECTION VII: ASSETS TRANSFERS
This section is for clarifying the specific details of any applicable asset transfers. If income is received from the sale of a asset, in addition to
reporting the details of the transfer in this section, ensure the remaining proceeds (if any) are reported as part of your assets within the other
appropriate sections of this form.
• Sold - Exchange of property ownership for monetary benefit
• Traded - Exchange of property ownership for alternative property
• Gave Away - Exchange of property ownership without benefit
• Conveyed - Exchange of property ownership through a legal process
NOTE: A transfer for less than fair market value means you disposed of an asset for less than the asset was worth..
SECTION VIII: TRUSTS
This section is for reporting aspects of trusts to include possible income(s), value and controlling interest. Trusts may be countable as an asset
and may generate income depending on the terms of the trust. If additional space is needed due to ownership of multiple trusts, submit VA
Form 21-4138, Statement in Support of Claim, with the information requested in this section for each additional trust. Provide the following
additional evidence for each trust:
• Initial contract from your financial institution establishing the trust
• Schedule of Assets must be included
SECTION IX: ANNUITIES

• Current statement showing surrender value and monthly payments

This section is for reporting annuity benefits. If additional space is needed due to ownership of multiple annuities, submit VA Form 21-4138,
Statement in Support of Claim, with the information requested in this section for each additional annuity. You may need to submit the following
evidence for each annuity:
• Initial contract from your financial institution
SECTION X: ASSETS PREVIOUSLY NOT PREPORTED

• Current statement showing surrender value and monthly payments

This section is for reporting any assets that have not been reported previously. For proceeds from asset transfers identified in Section VI, only
include assets that you still have access to (not spent). Examples of assets that may not have been reported previously include:
• Non-Interest-Bearing Accounts
• Collectible Valuables
• Real Estate
• Cash
SECTION XI: DISCONTINUED OR IRREGULAR INCOME
This section is for reporting all discontinued or irregular income received during the period reported in question 2#. If this form is submitted with
your initial claim, submit information pertaining to the previous calendar years. You may need to submit copies of closed account documents, or
current statements showing non-receipt of income such as a bank statement with no generated interest. Examples of discontinued or irregular
income include:
• Discontinued Wages
• Interest or Dividends from Depleted Accounts
• Unemployment Income
• Lottery or Gambling Winnings
These incomes are typically classified as:
• Recurring - Income that occurred at a regular interval
• One-time - Income that only occurred once
VA FORM 21P-0969, XXXX

• Irregular - Income received several times during the reporting period
at irregular intervals or irregular amounts.
Page 2

NOTICE
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-ofattorney and the fee agreement requirements.
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, 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 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 30 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 3

OMB Control No. 2900-0829
Respondent Burden: 30 minutes
Expiration Date: XXXXXXXX

INCOME AND ASSET STATEMENT IN SUPPORT OF CLAIM FOR PENSION OR
PARENTS' DEPENDENCY AND INDEMNITY COMPENSATION (D.I.C.)
SECTION I: VETERAN'S IDENTIFICATION INFORMATION

1A. VETERAN'S NAME (First, Middle Initial (M.I.), Last)
First:

MI:

Last:

1B. VETERAN'S SOCIAL SECURITY NUMBER

1C. VETERAN'S FILE NUMBER (If known)

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION
(If you are the Veteran, skip questions 2A and 2B)
2A. CLAIMANT'S NAME (First, Middle Initial (M.I.), Last)
First:

MI:

Last:

2B. CLAIMANT'S SOCIAL SECURITY NUMBER

2C. CLAIMANT'S TELEPHONE NUMBER (If known)

2D. TYPE OF CLAIMANT (Check only one box)
VETERAN

SURVIVING SPOUSE

SURVIVING CHILD

PARENT

CUSTODIAN OF CHILD BENEFICIARY

This form is designed to provide VA with your income and net worth during a specific date range to determine your eligibility or adjust your benefits. If you are submitting an
initial application, report current information. Your effective date is typically the:
• Date VA receives your application
• Date VA receives your intent to file
• Date of Veteran's death (Survivor's Benefits only)
If you are submitting this form as a response to VA correspondence, report your income and net worth information during the date range specified in that correspondence.
If you are reporting an income change, report changes from the date the change took effect.
NOTE: Submit a separate VA Form 21P-0969 if reporting income and net worth information for additional date ranges.
2E. THE INFORMATION ON THIS FORM REPORESENTS INCOME AND NET WORTH FOR THE FOLLOWING PERIOD:
THROUGH

DATE RECEIVED BY VA (For initial claims only.)

-OR-

SECTION III: RECURRING INCOME NOT ASSOCIATED WITH ACCOUNTS OR ASSETS
(See instructions on Page 3)
3A. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE ANY INCOME IN THE NEXT 12 MONTHS FROM SOURCES NOT RELATED TO AN
ACCOUNT OR YOUR ASSETS?
NO (If "NO," skip to Section IV)

YES

3B. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN
PARENT

SPOUSE

CUSTODIAN OF CHILD

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT
(Child, parent, or other only)

OTHER (Specify)

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY
CIVIL SERVICE

(4). GROSS MONTHLY INCOME

RETIREMENT/PENSION

WAGES

UNEMPLOYMENT
$

OTHER (Specify)

,

.

(5). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

3C. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN
PARENT

SPOUSE

CUSTODIAN OF CHILD

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT
(Child, parent, or other only)

OTHER (Specify)

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY
CIVIL SERVICE

(4). GROSS MONTHLY INCOME

RETIREMENT/PENSION

WAGES

UNEMPLOYMENT
$

OTHER (Specify)

,

.

(5). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

VA FORM
XXXX

21P-0969

SUPERSEDES VA FORM 21P-0969, DEC 2021

Page 4

SECTION III: RECURRING INCOME NOT ASSOCIATED WITH ACCOUNTS OR ASSETS - Continued
(See instructions on Page 3)
3D. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT
(Child, parent, or other only)

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

(4). GROSS MONTHLY INCOME

RETIREMENT/PENSION

CIVIL SERVICE

WAGES

UNEMPLOYMENT
$

OTHER (Specify)

,

.

(5). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

3E. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT
(Child, parent, or other only)

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

(4). GROSS MONTHLY INCOME

RETIREMENT/PENSION

CIVIL SERVICE

WAGES

UNEMPLOYMENT
$

OTHER (Specify)

,

.

(5). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

3F. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT
(Child, parent, or other only)

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

(4). GROSS MONTHLY INCOME

RETIREMENT/PENSION

CIVIL SERVICE

WAGES

UNEMPLOYMENT
$

OTHER (Specify)

,

.

(5). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

SECTION IV: INCOME AND NET WORTH ASSOCIATED WITH FINANCIAL ACCOUNTS
(See instructions on Page 3)
4A. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE ANY INCOME IN THE NEXT 12 MONTHS THAT IS RELATED TO FINANCIAL
ACCOUNTS?
YES

NO (If "NO," skip to Section V)
(4). SPECIFY THE TYPE OF INCOME EARNED

4B. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

INTEREST

CHILD

OTHER

(2). SPECIFY NAME OF INCOME RECIPIENT (Child, parent, or other only)

(5). GROSS MONTHLY INCOME
$

(3). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

,

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

INTEREST

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT (Child, parent, or other only)

,

.

(3). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

DIVIDENDS

OTHER
(5). GROSS MONTHLY INCOME
$

,

.

(6). VALUE OF ACCOUNT
$

VA FORM 21P-0969, XXXXXX

,

(4). SPECIFY THE TYPE OF INCOME EARNED

4C. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
SPOUSE

.

(6). VALUE OF ACCOUNT
$

VETERAN

DIVIDENDS

,

,

.

Page 5

SECTION IV: INCOME AND NET WORTH ASSOCIATED WITH FINANCIAL ACCOUNTS - Continued
(See instructions on Page 3)
(4). SPECIFY THE TYPE OF INCOME EARNED

4D. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

INTEREST

CHILD

OTHER

(2). SPECIFY NAME OF INCOME RECIPIENT (Child, parent, or other only)

(5). GROSS MONTHLY INCOME
$

(3). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

,

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

,

INTEREST

CHILD

(3). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

,

OTHER (Specify)

,

,

.

(4). SPECIFY THE TYPE OF INCOME EARNED

4F. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
CUSTODIAN OF CHILD

.

(6). VALUE OF ACCOUNT
$

PARENT

DIVIDENDS

(5). GROSS MONTHLY INCOME
$

SPOUSE

.

OTHER

(2). SPECIFY NAME OF INCOME RECIPIENT (Child, parent, or other only)

VETERAN

,

(4). SPECIFY THE TYPE OF INCOME EARNED

4E. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
SPOUSE

.

(6). VALUE OF ACCOUNT
$

VETERAN

DIVIDENDS

INTEREST

CHILD

DIVIDENDS

OTHER

(2). SPECIFY NAME OF INCOME RECIPIENT (Child, parent, or other only)

(5). GROSS MONTHLY INCOME
$

(3). SPECIFY INCOME PAYER (Name of business, financial institution, or program, etc.)

,

.

(6). VALUE OF ACCOUNT
$

,

,

.

SECTION V: INCOME AND NET WORTH ASSOCIATED WITH OWNED ASSETS
(See instructions on Page 3)
5A. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE ANY INCOME IN THE NEXT 12 MONTHS GENERATED BY OWNED PROPERTY
OR OTHER PHYSICAL ASSETS?
YES

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

5B. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

(4). GROSS MONTHLY INCOME
CHILD
$

,

.

(5). SPECIFY VALUE OF YOUR PORTION OF
THE PROPERTY

(2). SPECIFY NAME OF INCOME RECIPIENT (Child, parent, or other only)

$

,

,

.

(3). IDENTIFY THE TYPE OF ASSET AND SUBMIT THE REQUIRED FORM ASSOCIATED
FARM - VA FORM 21P-4165

BUSINESS - VA FORM 21P-4185

RENTAL PROPERTY - VA FORM 21P-4185

5C. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

(4). GROSS MONTHLY INCOME
CHILD
$

,

.

(5). SPECIFY VALUE OF YOUR PORTION OF
THE PROPERTY

(2). SPECIFY NAME OF INCOME RECIPIENT (Child, parent, or other only)

$

,

,

.

(3). IDENTIFY THE TYPE OF ASSET AND SUBMIT THE REQUIRED FORM ASSOCIATED
FARM - VA FORM 21P-4165

VA FORM 21P-0969, XXXXXX

BUSINESS - VA FORM 21P-4185

RENTAL PROPERTY - VA FORM 21P-4185

Page 6

SECTION VI: INCOME AND NET WORTH ASSOCIATED WITH ROYALTIES AND OTHER PROPERTIES
(See instructions on Page 3)
6A. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE ANY INCOME AND NET WORTH ASSOCIATED WITH ROYALTIES AND OTHER
PROPERTIES?
YES

NO (If "NO," skip to Section VII)
(2). SPECIFY NAME OF INCOME RECIPIENT
(Child, parent, or other only)

6B. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

(3). SPECIFY HOW INCOME IS GENERATED FROM THIS ASSET
BENEFITS FROM INTELLECTUAL PROPERTY

EXTRACTION OF MINERALS/LUMBER

USE OF LAND

OTHER
(5). SPECIFY FAIR MARKET VALUE OF THIS ASSET

(4). GROSS MONTHLY INCOME
$

,

.

$

,

,

(6). CAN THE ASSET BE SOLD?

.

YES

NO

(7). EXPLAIN ANY MITIGATING CIRCUMSTANCES THAT PREVENT THE SALE OF THIS ASSET

(2). SPECIFY NAME OF INCOME RECIPIENT
(Child, parent, or other only)

6C. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

(3). SPECIFY HOW INCOME IS GENERATED FROM THIS ASSET
BENEFITS FROM INTELLECTUAL PROPERTY

EXTRACTION OF MINERALS/LUMBER

USE OF LAND

OTHER
(5). SPECIFY FAIR MARKET VALUE OF THIS ASSET

(4). GROSS MONTHLY INCOME
$

,

.

$

,

,

(6). CAN THE ASSET BE SOLD?

.

YES

NO

(7). EXPLAIN ANY MITIGATING CIRCUMSTANCES THAT PREVENT THE SALE OF THIS ASSET

SECTION VII: ASSET TRANSFERS
(See instructions on Page 3)
7A. IN THE CURRENT YEAR AND/OR PRIOR 3 TAX YEARS, DID YOU OR YOUR DEPENDENTS SELL, CONVEY, TRADE, OR GIVE AWAY ANY ASSETS?
YES

NO (If "NO," skip to Section VIII)
(7). SPECIFY DATE OF TRANSFER (MM/DD/YYYY)

7B. (1). SPECIFY ASSET'S ORIGINAL OWNER'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD
(8). WAS THE ASSET TRANSFERRED FOR LESS THAN FAIR
MARKET VALUE?

(2). SPECIFY HOW THE ASSET WAS TRANSFERRED
SOLD

GAVE AWAY

CONVEYED

OTHER (Specify)
(3). WHAT ASSET WAS TRANSFERRED?
(4). WHO RECEIVED THE ASSET?
(5). RELATIONSHIP TO NEW OWNER
(6). WAS THE SALE OF THE ASSET REPORTED TO THE IRS?
YES

NO

VA FORM 21P-0969, XXXX

TRADED

YES

NO

(9). WHAT WAS THE FAIR MARKET VALUE WHEN TRANSFERRED?
$

,

,

.

(10). WHAT WAS THE SALE PRICE? (If applicable)
$

,

,

.

(11). WHAT WAS THE GAIN? (Capital gain, etc.)
$

,

,

.

Page 7

SECTION VII: ASSET TRANSFERS - Continued
(See instructions on Page 3)
(7). SPECIFY DATE OF TRANSFER (MM/DD/YYYY)

7C. (1). SPECIFY ASSET'S ORIGINAL OWNER'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD
(8). WAS THE ASSET TRANSFERRED FOR LESS THAN FAIR
MARKET VALUE?

(2). SPECIFY HOW THE ASSET WAS TRANSFERRED
SOLD

GAVE AWAY

CONVEYED

YES

TRADED

(9). WHAT WAS THE FAIR MARKET VALUE WHEN TRANSFERRED?

OTHER (Specify)

$

(3). WHAT ASSET WAS TRANSFERRED?

$

(5). RELATIONSHIP TO NEW OWNER

NO

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

GAVE AWAY

,

.

,

,

.

CHILD
(8). WAS THE ASSET TRANSFERRED FOR LESS THAN FAIR
MARKET VALUE?

(2). SPECIFY HOW THE ASSET WAS TRANSFERRED
CONVEYED

YES

TRADED

NO

(9). WHAT WAS THE FAIR MARKET VALUE WHEN TRANSFERRED?

OTHER (Specify)

$

(3). WHAT ASSET WAS TRANSFERRED?

,

,

.

(10). WHAT WAS THE SALE PRICE? (If applicable)

(4). WHO RECEIVED THE ASSET?

$

(5). RELATIONSHIP TO NEW OWNER

,

,

.

(11). WHAT WAS THE GAIN? (Capital gain, etc.)

(6). WAS THE SALE OF THE ASSET REPORTED TO THE IRS?
YES

,

$

SPOUSE

.

(7). SPECIFY DATE OF TRANSFER (MM/DD/YYYY)

7D. (1). SPECIFY ASSET'S ORIGINAL OWNER'S RELATIONSHIP TO VETERAN
VETERAN

,

(11). WHAT WAS THE GAIN? (Capital gain, etc.)

(6). WAS THE SALE OF THE ASSET REPORTED TO THE IRS?

SOLD

,

(10). WHAT WAS THE SALE PRICE? (If applicable)

(4). WHO RECEIVED THE ASSET?

YES

NO

NO

$

,

,

.

SECTION VIII: ASSET TRUSTS
(See instructions on Page 3)
8A. HAVE YOU OR YOUR DEPENDENTS ESTABLISHED A TRUST OR DO YOU OR YOUR DEPENDENTS HAVE ACCESS TO A TRUST? (If you have more than one trust
to report, submit the information below on a separate VA Form 21P-0969 or provide the above information on VA Form 21-4138 for each trust established.)
YES

NO (If "NO," skip to Section IX)

8B. DATE TRUST WAS ESTABLISHED
(MM/DD/YYYY)

8C. SPECIFY MARKET VALUE OF ALL ASSETS
8D. SPECIFY TYPE OF TRUST ESTABLISHED
WITHIN THE TRUST AT TIME OF ESTABLISHEMENT
$

8E. HAVE YOU ADDED ADDITION FUNDS TO
THE TRUST AFTER IT WAS ESTABLISHED?

YES

,

,

.

8F. WHEN DID YOU TRANSFER ADDITIONAL
FUNDS? (MM/DD/YYYY)
(If more than one date, submit a VA Form 21-4138
with all dates and amounts)

$

$

8J. IS THE TRUST BEING USED TO PAY FOR OR TO REIMBURSE SOMEONE ELSE FOR YOUR
MEDICAL EXPENSES? (Such as guardian, family member or other service provider)
YES

YES

VA FORM 21P-0969, XXXX

,

.

,

.

8K. HOW MUCH IS BEING REIMBURSED MONTHLY?
$

NO

NO

BURIAL TRUST

8I. HOW MUCH DO YOU RECEIVE ANNUALLY?

NO

8L. WAS THE TRUST ESTABLISHED FOR A CHILD OF THE VETERAN WHO WAS
INCAPABLE OF SELF-SUPPORT PRIOR TO REACHING AGE 18?

IRREVOCABLE

8G. HOW MUCH DID YOU TRANSFER?

NO

8H. ARE YOU RECEIVING INCOME FROM THE TRUST?
YES

REVOCABLE

,

.

8M. DO YOU HAVE ANY ADDITIONAL AUTHORITY OR CONTROL OF THE
TRUST?
YES

NO

Page 8

SECTION IX: ANNUITIES
(See instructions on Page 3)
9A. HAVE YOU OR YOUR DEPENDENTS ESTABLISHED AN ANNUITY? (If you have more than one annuity to report, submit the information below on a separate VA Form
21P-0969, or provide the above information on VA Form 21-4138 for each annuity established.)
YES

NO (If "NO," skip to Section X)

9B. SPECIFY DATE ANNUITY WAS ESTABLISHED
(MM/DD/YYYY)

9C. SPECIFY MARKET ANNUITY WHEN
ORGINALLY PURCHASED
$

9E. SPECIFY DATE ADDITIONAL FUNDS WERE
TRANSFERRED (MM/DD/YYYY)

,

YES

NO

.

,

,

,

,

.

NO

9G. IS THE ANNUITY REVOCABLE OR IRREVOCABLE?

.

9I. IF YES IN 9H, PROVIDE ANNUAL AMOUNT
RECEIVED
$

YES

9F. HOW MUCH HAVE YOU TRANSFERRED?

$
9H. DO YOU RECEIVE INCOME FROM
THE ANNUNITY?

,

9D. HAVE YOU ADDED ADDITIONAL FUNDS TO THE
ANNUITY IN THE CURRENT OR PRIOR THREE YEARS?

REVOCABLE

9J. CAN THE ANNUITY BE
LIQUIDATED?
YES

NO

IRREVOCABLE

9K. IF YES IN 9J, PROVIDE THE
SURRENDER VALUE
$

,

,

.

SECTION X: ASSETS PREVIOUSLY NOT REPORTED
(See instructions on Page 3)
10A. DO YOU OR YOUR DEPENDENTS HAVE ASSETS NOT ALREADY REPORTED?
YES

NO (If "NO," skip to Section XI)

10B. (1). SPECIFY ASSET OWNER'S RELATIONSHIP TO THE VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

$

(2). SPECIFY TYPE OF ASSET (Cash, Art, etc.)

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

(2). SPECIFY TYPE OF ASSET (Cash, Art, etc.)

VA FORM 21P-0969, XXXX

,

.

,

,

.

(4). SPECIFY ASSET LOCATION ( Financial institution, property address, etc.)

10E. (1). SPECIFY ASSET OWNER'S RELATIONSHIP TO THE VETERAN
SPOUSE

,

(3). SPECIFY VALUE OF YOUR PORTION OF
THE PROPERTY
$

(2). SPECIFY TYPE OF ASSET (Cash, Art, etc.)

VETERAN

.

(4). SPECIFY ASSET LOCATION ( Financial institution, property address, etc.)

10D. (1). SPECIFY ASSET OWNER'S RELATIONSHIP TO THE VETERAN
SPOUSE

,

(3). SPECIFY VALUE OF YOUR PORTION OF
THE PROPERTY
$

(2). SPECIFY TYPE OF ASSET (Cash, Art, etc.)

VETERAN

,

(4). SPECIFY ASSET LOCATION ( Financial institution, property address, etc.)

10C. (1). SPECIFY ASSET OWNER'S RELATIONSHIP TO THE VETERAN
VETERAN

(3). SPECIFY VALUE OF YOUR PORTION OF
THE PROPERTY

CHILD

(3). SPECIFY VALUE OF YOUR PORTION OF
THE PROPERTY
$

,

,

.

(4). SPECIFY ASSET LOCATION ( Financial institution, property address, etc.)

Page 9

SECTION XI: DISCONTINUED OR IRREGULAR INCOME
(See instructions on Page 3)
11A. DID YOU OR YOUR DEPENDENTS RECEIVE INCOME THAT HAS STOPPED OR IS NO LONGER BEING RECEIVED WITHIN:
THE REPORTING PERIOD (From question 2E)? - OR - LAST FULL CALENDAR YEAR (For initial claim)?
YES

NO (If "NO," skip to Section XII)

11B. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

(5). SPECIFY FREQUENCY OF INCOME RECEIVED
RECURRING

CHILD

IRREGULAR

ONE-TIME PAYMENT
(6). DATE INCOME LAST PAID (MM/DD/YYYY)

(2). SPECIFY NAME OF INCOME RECIPIENT
(3). SPECIFY INCOME PAYER
(Name of business, financial institution, etc.)

(7). WHAT WAS THE GROSS ANNUAL AMOUNT
REPORTED TO THE IRS?

(4). SPECIFY TYPE OF INCOME RECEIVED (Interest, Dividends, etc.)

$
11C. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

,

.

(5). SPECIFY FREQUENCY OF INCOME RECEIVED
RECURRING

CHILD

IRREGULAR

ONE-TIME PAYMENT
(6). DATE INCOME LAST PAID (MM/DD/YYYY)

(2). SPECIFY NAME OF INCOME RECIPIENT
(3). SPECIFY INCOME PAYER
(Name of business, financial institution, etc.)

(7). WHAT WAS THE GROSS ANNUAL AMOUNT
REPORTED TO THE IRS?

(4). SPECIFY TYPE OF INCOME RECEIVED (Interest, Dividends, etc.)

$

,

.

SECTION XII: WAIVER OF RECEIPT OF INCOME
(See instructions on Page 3)
12A. DID YOU OR YOUR DEPENDENTS WAIVE OR EXPECT TO WAIVE ANY RECEIPT OF INCOME IN THE NEXT 12 MONTHS?
YES

NO (If "NO," skip to Section XIII Certification and Signature)
(5). DATE PAYENTS WILL RESUME (MM/DD/YYYY)

12B. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT

This income will not resume

(3). SPECIFY INCOME PAYER
(Name of business, financial institution, etc.)

(6). WAIVED GROSS MONTHLY INCOME
$

(4). IF THE INCOME RESUMES, WHAT AMOUNT DO YOU EXPECT TO RECEIVE?

$

,

SPOUSE

PARENT

OTHER (Specify)

CUSTODIAN OF CHILD

.

.
(5). DATE PAYENTS WILL RESUME (MM/DD/YYYY)

12C. (1). SPECIFY INCOME RECIPIENT'S RELATIONSHIP TO VETERAN
VETERAN

,

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT

This income will not resume

(3). SPECIFY INCOME PAYER
(Name of business, financial institution, etc.)

(6). WAIVED GROSS MONTHLY INCOME
$

(4). IF THE INCOME RESUMES, WHAT AMOUNT DO YOU EXPECT TO RECEIVE?

$

,

,

.

.

SECTION XIII: CERTIFICATION AND SIGNATURE
I CERTIFY THAT the statements on the form are true and correct to the best of my knowledge and belief. I UNDERSTAND THAT without consent, the Department of
Veterans Affairs (VA) may disclose information that I provide to entities under a published "routine use." Under such a routine use, the VA may disclose information to third party
entities that participate in VA claims processing and are authorized to assist the VA in administering benefits; to other federal agencies under computer matching programs, such
as those with the Internal Revenue Service, Social Security Administration, Selective Service System, Department of Homeland Security, Department of Justice; and to members
of Congress if they are assisting to help with Veteran's benefit questions.
13A. SIGNATURE
13B. DATE SIGNED (MM/DD/YYYY)

VA FORM 21P-0969, XXXX

Page 10

SECTION XIV: WITNESS TO SIGNATURE
(Two witness signatures are required if the claimant signed item 13A with an "X")
14A. SIGNATURE OF FIRST WITNESS
(If claimant signed above using an "X")
14B. PRINTED NAME AND ADDRESS OF FIRST WITNESS
FIRST:

MI:

LAST:

14C. ADDRESS OF FIRST WITNESS
No. &
Street

Apt./Unit
Number

City
State/Province

Country

ZIP Code/Postal Code

14D. SIGNATURE OF FIRST WITNESS
(If claimant signed above using an "X")
14E. PRINTED NAME AND ADDRESS OF FIRST WITNESS
FIRST:

MI:

LAST:

14F. ADDRESS OF FIRST WITNESS
No. &
Street

Apt./Unit
Number

City
State/Province

Country

ZIP Code/Postal Code

Where to Send Correspondence - After completing the form, mail to:
Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, WI 53547-5365
PENALTY: The law provides severe penalties (including fine and/or imprisonment) for willfully submitting any statement or evidence of a material fact you know to be false, or
for fraudulent receipt of any document you are not entitled to.

VA FORM 21P-0969, XXXX

Page 11