Form VA FL 21-914 VA FL 21-914 Residency Verification Report - Veterans and Survivors

In Reply Refer To:

What Is The Purpose Of This Letter?
We are sending you this letter to determine whether we can continue to pay your VA compensation or
dependency and indemnity compensation (DIC) benefits at the full-dollar rate.
To receive benefits at the full-dollar rate you must:
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•
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Be present in the U.S. for at least 183 days of each year, and
Not be absent from the U.S. for more than 60 days at a time without good cause, and
Be a U.S. citizen or permanent resident alien, and
Let us know if you change your address.

What Calendar Year Are The Questions Below Related To?
Please provide answers to the below questions for the prior calendar year. For example, if this letter is
printed on February 2014, your response should be in regards to the 2013 calendar year.
What Must I Do Now?
Answer questions 1 through 6 below to verify that you continue to be eligible for VA benefits at the fulldollar rate.
What Will Happen If I Don't Complete and Return This Letter?
If we do not receive a response from you within 60 days from the date of this letter, your benefits will be
reduced to the half-dollar rate.
Do You Have Questions or Need Assistance?
If you have any questions or need assistance, please call 1-800-827-1000 (Hearing Impaired
TDD line 1-800-829-4833).

Department of Veterans Affairs

OMB Control No. 2900-0655
Respondent Burden: 5 Minutes
Expiration Date: XX/XX/XXXX
1. DID YOU LEAVE THE UNITED STATES (states, territories, and possessions, the District of Columbia and Puerto Rico) at any time during
calendar year? Note: Do not include any trip, such as a trip to Mexico or Canada, in which you left from and returned to the U.S. on the same
day.

YES

NO

(If "Yes," attach a separate sheet of paper listing each period of absence separately, showing the date you left the
U.S. and the date you returned, and send us a copy of your passport visas or reentry permits with entrance and exit
date stamps. Also state on the separate sheet of paper the cause of absence, if you were absent from the U.S. for
more than 60 consecutive days.)

2. DID YOU LOSE YOUR U.S. CITIZENSHIP OR PERMANENT RESIDENT ALIEN STATUS DURING CALENDAR YEAR?

YES

NO

(If "Yes," send us a copy of the Immigration and Naturalization Service (INS) notice which shows the
date that your citizenship or permanent resident alien status ended.)

3A. DID YOU NOTIFY US OF A CHANGE IN YOUR ADDRESS DURING CALENDAR YEAR?

(If "No," complete Item 3B, and send us evidence that you live at this address, such as a current lease or purchase
agreement or utility bill (telephone, gas or electric.)
3B. CURRENT STREET MAILING ADDRESS (Number, street, or rural route, city, state, and ZIP Code)
YES

NO

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge.
4. SIGNATURE

5. DATE SIGNED

6. TELEPHONE NO.(S) (Include Area Code)
Daytime
Evening

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement
or evidence of a material fact, knowing it to be false.
FL 21-914
See Reverse For Important Information
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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 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 under the law. 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.
IMPORTANT NOTICE ABOUT INFORMATION COLLECTION: We need this information to verify that
you are eligible for payment of benefits at the full-dollar rate (38 U.S.C. 107). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 5 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 http: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.

FL 21-914
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