Form 21P-534EZ Application for DIC, Death Pension, and/or Accrued Benef

NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR DEPENDENCY
AND INDEMNITY COMPENSATION, SURVIVORS PENSION, AND/OR ACCRUED BENEFITS
This notice provides information regarding evidence necessary to substantiate a claim for:
• Survivors Pension
• Dependency Indemnity Compensation (D.I.C.)
• D.I.C. under 38 U.S.C. 1151
• D.I.C. re-evaluation based on PL 117-16 (PACT ACT)
• Increased Survivor Benefits Based on Need for Special Monthly Pension or Special Monthly D.I.C.
• Accrued Benefits
• Benefits Based on a Veteran's Seriously Disabled Child
If you are making a claim for:
Pension Benefits

Complete and Submit VA Form 21P-527EZ, Application for Veterans Pension

Compensation Benefits

Complete and Submit VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits

Parents' D.I.C Benefits

Complete and Submit VA Form 21P-535, Application for Dependency and Indemnity Compensation by Parent(s)
(Including Accrued Benefits and Death Compensation when Applicable)

Accrued Benefits

Complete and Submit VA Form 21P-601, Application for Accrued Benefits Due a Deceased Beneficiary

Supplemental Claim

Complete and Submit VA Form 20-0995, Decision Review Request: Supplemental Claim

If you are not ready to submit a claim for D.I.C., Survivors Pension, and/or Accrued Benefits, please complete a VA Form 21-0966,
Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or D.I.C., to protect your date of claim. If you
complete the VA Form 21P-534EZ within one year of filing the VA Form 21-0966, your completed application will be considered filed as
of the date of receipt of the VA Form 21-0966.
VA forms are available at www.va.gov/vaforms.
For more information on survivors benefits see https://www.va.gov/family-and-caregiver-benefits/survivor-compensation/dependencyindemnity-compensation/

ASSISTANCE WITH COMPLETING YOUR CLAIM
Veteran Service Officer (VSO)
You may wish to contact an accredited Veteran Service Officer to assist you with your application. For a list of accredited Veteran's Service
Organizations go to https://www.va.gov/vso/. You may also contact your state office of Veterans Affairs at https://www.va.gov/statedva.htm.
To assign a VSO as your power of attorney for the claims process, submit VA Form 21-22, Appointment of Veteran Service Organization as
Claimant's Representative.
Private Attorney and Claims Agents
Attorneys and claims agents are available to assist you in completing your application. To verify if your attorney or claims agent is
accredited by the Department of Veterans Affairs go to: https://www.va.gov/ogc/apps/accreditation/index.asp. To assign a private
attorney for the claims process, submit a VA Form 21-22a, Appointment of Individual as Claimant's Representative.
Fees for Claims
Generally, an accredited attorney or claims agent can ONLY charge claimants a fee after the VA has issued a decision on a claim.
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.

VA FORM
XXX 20XX

21P-534EZ

SUPERSEDES VA FORM 21-534EZ, JUL 2022.

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WHEN TO USE THIS FORM

The attached application is needed to submit a claim for D.I.C., Survivors Pension and/or Accrued Benefits. There are worksheets

included to help verify care expenses if you claim them. This notice details the evidence necessary to substantiate your claim. Leave
items in a section blank if they do not apply to you.

THIS APPLICATION HAS 14 SECTIONS
SECTION I:

VETERAN'S IDENTIFICATION INFORMATION

SECTION II:

CLAIMANT'S IDENTIFICATION INFORMATION

SECTION VIII:

NURSING HOME OR INCREASED SURVIVORS
ENTITLEMENT BASED ON A CLAIM FOR A SPECIAL
MONTHLY PENSION

SECTION III:

VETERAN'S SERVICE INFORMATION

SECTION IV:

MARITAL INFORMATION

SECTION IX:

SECTION V:

MARITAL HISTORY

SECTION X:

SECTION VI:

CHILD OF VETERAN INFORMATION

INFORMATION ABOUT YOUR MEDICAL OR OTHER
EXPENSES

SECTION VII:

D.I.C

INCOME AND ASSETS

SECTION XI:

DIRECT DEPOSIT INFORMATION

SECTION XII:

CLAIM CERTIFICATION AND SIGNATURE

SECTION XIII:

WITNESSES TO SIGNATURE

SECTION XIV:

ALTERNATE SIGNER CERTIFICATION ANDSIGNATURE

To qualify you must:
1. Submit your claim on a completed, signed and dated VA Form 21P-534EZ, Application for D.I.C., Survivors Pension, and/or
Accrued Benefits (Attached).
2. Submit simultaneously with your claim:
• A copy of the veteran's death certificate (unless the veteran died on active duty); AND
If claiming Survivor's Pension:
• All necessary income and asset information; AND
• Any additional forms and evidence as the situation requires. Special Circumstances below indicate the most common
circumstances. The application and other VA Forms may require additional evidence.
If claiming D.I.C.:
• All, if any, of the veteran's relevant, private medical treatment records and an identification of any of the veteran's treatment
records available at a Federal facility, such as a VA medical center, that supports your claim that a service-connected disability
caused the veteran's death or the veteran's death was caused by the VA;
• Any and all Service Treatment and Personnel Records in the custody of the veteran's Guard or Reserve Unit(s) if applicable; AND
• Any additional forms and evidence as the situation requires. Special Circumstances below indicate the most common
circumstances. The application and other VA Forms may require additional evidence.
3. Report for any VA examinations VA determines are necessary to decide your claim.
For more information on VA benefits, visit our website at www.va.gov, contact us at https://www.va.gov/contact-us or call us toll-free at
1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the number is 711.
SPECIAL CIRCUMSTANCES:
Additional forms may be needed to remain eligible.
This includes VA Form 21P-0969, Income and Asset Statement in Support of Claim for Pension or Parents' D.I.C., which may be
required if you:
• Have multiple income sources
• Have more than $75,000 in assets
• Additional forms as noted on the VA Form 21P-0969 may be required
If claiming Special Monthly Pension or Special Monthly D.I.C.:
• Please have a Physician, Physician Assistant (PA), Certified Nurse Practitioner (CNP), or Clinic Nurse Specialist (CNS)
complete VA Form 21-2680, Examination for Household Status or Permanent Need for Regular Aid and Attendance, OR
• If you are a patient in a nursing home complete VA Form 21-0779, Request for Nursing Home Information in Connection with
Claim for Aid and Attendance
If claiming benefits for a child of the veteran:
• And they are in school between the ages of 18 and 23, a completed VA Form 21-674, Request for Approval of School
Attendance
• If the child was adopted, please submit the adoption papers or amended birth certificate
• If claiming benefits for a child of the veteran who became seriously disabled prior to reaching the age of 18, submit all, if any,
relevant private medical treatment records for the child's pertinent disabilities
• If the child is over 18 and you are claiming DIC, the child will have to apply for DIC with their own application.
VA FORM 21P-534EZ, XXX 20XX

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SUBMITTING A CLAIM
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. If your claim involves a disability the veteran had before entering service and that was made worse by
service, please provide any information or evidence in your possession regarding the health condition that existed before the veteran's
entry into service. A substantially complete claim must contain: (1) The claimant's name; (2) Their relationship to the veteran (3)
Sufficient service information for VA to verify the claimed service, if applicable; (4) The benefit sought and any medical condition(s) on
which it is based; (5) The claimant's signature; (6) A statement of income, if applicable.

HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
VA will retrieve evidence on your behalf in some circumstances. If VA is unable to retrieve the necessary evidence, we 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.
VA will:
• Retrieve relevant records from a Federal facility that you adequately identify and authorize VA to obtain.
• 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 from current or former employers.

WHEN YOU SHOULD SEND WHAT WE NEED
You are strongly encouraged to:
• Send any information or evidence as soon as you can.
NOTE: 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 received the claim, you will still have the remainder of the one year
period to submit additional information or evidence necessary to support the claim. In order to go back to your original effective date,
you will need to submit a supplemental claim if you choose to submit the necessary information or evidence within that year.

VA FORM 21P-534EZ, XXX 20XX

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WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
If you are claiming...
Survivors Pension (an income and asset-based benefit for
surviors of a veteran with wartime service)

See Evidence Tables titled...
Military Service Verification
Survivors Pension

D.I.C. because the veteran's death was related to
the veteran's service, OR
D.I.C. because the veteran was receiving or entitled to receive
benefits for a service-connected disability rated totally disabling

Dependency and Indemnity Compensation (D.I.C.)

D.I.C. because the veteran's death was a result of VA medical
treatment, vocational rehabilitation, or compensated work therapy

D.I.C. under 38 U.S.C. 1151

D.I.C. re-evaluation of a previously denied claim based on
eligibility under PL 117-168 (PACT Act)

D.I.C. re-evaluation based on PL 117-168 (PACT Act)

D.I.C. that was previously denied by VA

Supplemental D.I.C.

Special Monthly Pension or Special Monthly D.I.C. based on the
need for aid and attendance or housebound benefits
Benefits that were due to the veteran at the time of the veteran's
death

Increased Survivor Benefits Based on Special Monthly Pension
or Special Monthly D.I.C.

Benefits because the child of the veteran is severely disabled

Child incapable of self-support

Accrued Benefits

EVIDENCE TABLES
MILITARY SERVICE VERIFICATION
To support your claim for Survivors benefits, the veteran's military service must be verified. The following evidence can be
submitted to verify the veteran's military service:
• A photocopy of the veteran's DD 214 (or equivalent) for all periods of military service. You may request a copy of the DD 214
through the National Archives' National Personnel Records Center (NPRC) using Standard Form 180 (SF-180), Request
Pertaining to Military Records, (available at https://www.gsa.gov/forms) or through your local public custodian of records
Fire Related Military Records
As you may know, there was a fire at the National Archives and Records Administration on July 12, 1973, which destroyed
approximately:
• 80 percent of the records NPRC held for Veterans who were discharged from the Army between November 1, 1912, and
January 1, 1960, and
• 75 percent of the records NPRC held for Veterans with surnames beginning (alphabetically) with Hubbard and running through
the end of the alphabet, and who were discharged from the Air Force between September 25, 1947, and January 1, 1964.
If the veteran's military records were stored there on that date, they may have been destroyed in the fire. If you believe the veteran's
military records may have been destroyed in the fire, NA Form 13075, Questionnaire About Military Service, should be completed to
avoid delays in processing your claim. NA Form 13075 is available at:
https://www.archives.gov/files/st-louis/military-personnel/na-13075-questionnaire-about-military-service.pdf.
NOTE: The Veterans Benefits Administration (VBA) is no longer able to retrieve or return original documents submitted. Please do
not submit original documents to VA since they will not be returned to you.
SURVIVORS PENSION
To support your claim for Survivors Pension, the evidence must show:
1. The veteran 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 the veteran's 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 obligations.); OR
• any length of active service during a period of war when:
• at the time of death, the veteran was receiving (or entitled to receive) VA disability compensation or retirement pay for a
service-connected disability; OR
• the veteran was discharged from active service due to a service-connected disability.
2. Your income and assets do not exceed certain requirements.
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 that does not exceed 2 acres, unless the additional acreage is not
marketable) 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.
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EVIDENCE TABLES (Continued)
DEPENDENCY AND INDEMNITY COMPENSATION (D.I.C.)
To support a claim for Dependency and Indemnity Compensation (D.I.C.) based on a service-connected disability:
• The veteran died while on active service; OR
• The veteran had a service-connected disability(ies) that was either the principal or contributory cause of the veteran's death; OR
• The veteran died from non-service-connected injury or disease AND was receiving, or entitled to receive VA compensation for a
service-connected disability rated totally disabling:
• For at least 10 years immediately before death; OR
• For at least 5 years after the veteran's release from active duty preceding death; OR
• For at least 1 year before death, if the veteran was a former prisoner of war who died after September 30, 1999.
To support a claim for D.I.C. based on a disability VA had not previously determined was service-connected or for which the
veteran did not file a claim during their lifetime, the evidence must show:
• An injury or disease that was incurred or aggravated during active service, or an event in service that caused an injury or
disease; AND
• A physical or mental disability that was either the principle or contributory cause of death. This may be shown by medical
evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND
• A relationship between the disability associated with the cause of death and an injury, disease, or event in service. This may be
shown by medical records or medical opinion or, in certain cases, by lay evidence.
To support your claim for D.I.C. based upon the service person's active duty for training, the evidence must show:
• The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty and the
disease or injury caused or contributed to the service person's death.
NOTE: If VA granted service connection for a disease or injury during the service person's lifetime, evidence that the serviceconnected disease or injury caused or contributed to the service person's death may satisfy this requirement.
To support a claim for D.I.C. based on a disability that was not service-connected or for which the service person did not file a
claim during their lifetime, the evidence must show:
• The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty; AND
• A physical or mental disability that was either the principle or contributory cause of death. This may be shown by medical
evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND
• A relationship between the principal or contributory cause of death and the disability due to injury or disease, incurred in the line
of duty. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.
To support your claim for D.I.C. based upon the service person's inactive duty training, the evidence must show:
• The service person died during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute
myocardial infarction, cardiac arrest, or cerebrovascular accident during such training; OR
• The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute
myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; and that injury, acute
myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service person's death.
NOTE: If VA granted service connection for an injury, acute myocardial infarction, or cerebrovascular accident during the service
person's lifetime, evidence that the service-connected condition caused or contributed to the service person's death may satisfy this
requirement.
To support a claim for D.I.C. based on a disability that was not service-connected or for which the service person did not file a
claim during their lifetime, the evidence must show:
• The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute
myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; AND
• The injury, acute myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service person's
death.
D.I.C. UNDER 38 U.S.C. 1151
In order to support your claim for D.I.C. under 38 U.S.C. 1151, the evidence must show:
• The deceased veteran died as a result of undergoing VA hospitalization, medical or surgical treatment, examination, or training;
AND
• The death was:
• the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment; OR
• the direct result of an event that was not a reasonably expected result or complication of the VA care or treatment; OR
• the direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy program.

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EVIDENCE TABLES (Continued)
D.I.C. RE-EVALUATION BASED ON PL 117-168 (PACT ACT)
Public Law 117-168 (PACT ACT) was signed into law on August 10, 2022. This resulted in a substantial expansion of a veteran's
military service that qualifies for presumptive toxic exposure and new presumptive conditions linked to that exposure. The law allows
prior claimants for D.I.C. to request a re-evaluation based on the expanded eligibility within the PACT Act. More information about
the PACT Act can be found at https://www.va.gov/resources/the-pact-act-and-your-va-benefits/.
In order to support your claim for D.I.C. re-evaluation based on PL 117-168 (PACT Act) the evidence must show:
• A claim was submitted and denied prior to August 10, 2022, the date the PACT Act went into effect; AND
• The claimant has elected re-evaluation of the previously denied claim.
SUPPLEMENTAL CLAIM D.I.C.
In order to reopen a claim previously denied by VA, we need:
• The prescribed supplemental claim form, VA Form 20-0995, Decision Review Request: Supplemental Claim; AND
• New and relevant evidence. New and relevant evidence must raise a reasonable possibility of substantiating your claim. The
evidence cannot simply be repetitive or cumulative of the evidence we had when we previously decided your claim. VA will
make reasonable efforts to help you obtain currently existing evidence. However, we cannot provide a medical examination or
obtain a medical opinion until your claim is successfully reopened.
• To qualify as new evidence is evidence not previously part of the actual record before agency adjudicators.
• In order to be considered relevant, the evidence is information that tends to prove or disprove a matter at issue in a claim.
Relevant evidence includes evidence that raises a theory of entitlement that was not previously addressed.
INCREASED SURVIVOR BENEFITS BASED ON SPECIAL MONTHLY PENSION OR SPECIAL MONTHLY D.I.C.
In order to support your claim for increased survivor benefits based on the need for aid and attendance, the evidence must
show:
• you have corrected vision of 5/200 or less in both eyes; OR
• you have concentric contraction of the visual field to 5 degrees; OR
• you are a patient in a nursing home due to mental or physical incapacity; OR
• you require the aid of another person to perform personal functions required in everyday living, such as bathing, feeding,
dressing yourself, attending to the wants of nature, adjusting prosthetic devices, or protecting yourself from the hazards of your
daily environment (38 Code of Federal Regulations 3.352(a)); OR
• you are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed course of
convalescence or treatment (38 Code of Federal Regulations 3.352(a)); OR
In order to support your claim for increased benefits based on being housebound, the evidence must show:
• you are substantially confined to your immediate premises because of permanent disability
ACCRUED BENEFITS
To support a claim for accrued benefits, the evidence must show:
• Benefits were due the veteran based on existing ratings, decisions, or evidence in VA's possession at the time of death, but the
benefits were not paid before the veteran's death; AND
• You are the surviving spouse, child, or dependent parent of the deceased veteran
VA pays accrued benefits in the following order of priority:
1. Spouse
2. Children of the veteran (in equal shares) 3. Dependent parents (in equal shares)
NOTE: Child means an unmarried child of the veteran who is under 18 years of age, or at least 18 but under 23 years of age and
pursuing an approved course of education or became incapable of self-support prior to reaching age 18.
If there are no living persons who are entitled on the basis of relationship, accrued benefits may be used to reimburse the person or
persons who paid for or are responsible to pay the expenses of last illness and burial of a beneficiary. The claim should be filed by
the person or persons whose funds were or will be used to pay such expenses using VA Form 21P-601, Application for Accrued
Amounts Due a Deceased Beneficiary.
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 their 18th birthday became permanently incapable of self-support due to mental or physical disability. The information
necessary to establish the extent of the child's disability includes:
• the extent to which the child is and was, prior to reaching their 18th birthday, physically or mentally deficient as evidenced by
factors such as their ability to perform self-care functions, and ordinary tasks expected of a child of that age
• whether or not the child attended school and, if so, the maximum grade attended
• if any material improvement in the child's condition has occurred
• if the child has ever been employed and, if so, the nature and dates of such employment, and amount of pay received
• whether or not the child has ever been married, and
• a description of the child's present condition
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PRESUMPTIVE SERVICE CONNECTION
To support a claim for presumptive service connection the evidence must show:
• The veteran served in a recognized location that qualifies for the presumption of exposure; AND/OR
• The veteran died of a disability that qualifies for the presumption of service connection. This may be shown by medical evidence
or by lay evidence of persistent and recurrent symptoms of disability that are visible or observable
Under certain circumstances, VA may presume that certain current diseases were caused by service, even if there is no specific
evidence proving this in your particular claim. Service connection is presumed for certain diseases for the following veterans:
• Former prisoners of war;
• Veterans who have certain chronic or tropical diseases that become evident within a specific period of time after discharge from
service;
• Veterans who were exposed to ionizing radiation, mustard gas, or Lewisite while in service;
• Veterans who were exposed to certain herbicides, such as by service in/on:
• Vietnam or qualifying offshore waters, from January 9, 1962, through May 7, 1975;
• a unit determined by VA or the Department of Defense to have operated in the Korean DMZ, from September 1, 1967, through
August 31, 1971;
• individuals who performed service in the Air Force or Air Force Reserve and regularly and repeatedly operated, maintained,
or served on board C-123 aircraft known to have used to spray an herbicide agent during the Vietnam era;
• Thailand at any United States or Royal Thai base, from January 9, 1962, through June 30, 1976;
• Laos, from December 1, 1965, through September 30, 1969;
• Cambodia at Mimot or Krek, Kampong Cham Province, from April 16, 1969, through April 30, 1969;
• Guam or American Samoa, or in the territorial waters thereof, from January 9, 1962, through July 31, 1980;
• Johnston Atoll or on a ship that called at Johnston Atoll, from January 1, 1972, through September 30, 1977.
• Veterans who served at Camp Lejeune for no less than 30 days (consecutive or nonconsecutive) between August 1, 1953 and
December 31,1987; OR
• Veterans who served in the Gulf War:
• On or after August 2, 1990, and served in:
• Bahrain; Iraq; the neutral zone between Iraq and Saudi Arabia; Kuwait; Oman; Qatar; Saudi Arabia; Somalia; United Arab
Emirates; the Gulf of Aden; the Gulf of Oman; the Persian Gulf; the Arabian Sea; the Red Sea; Afghanistan; Israel; Egypt;
Turkey; Syria; or Jordan; OR
• On or after September 11, 2001, and served in:
• Afghanistan; Djibouti; Egypt; Jordan; Lebanon; Syria; Yemen; or Uzbekistan.
IMPORTANT INFORMATION REGARDING MARRIAGE
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 recognizes marriages is available
at http://www.va.gov/opa/marriage/.

HOW VA DETERMINES THE EFFECTIVE DATE
If we grant a claim for Survivors Benefits, the beginning date of your entitlement will generally be the date we received your claim, or the
intent to file (ITF) for Survivor Benefits, if received within a year of the ITF. If VA receives your claim within one year after the veteran's
death, the entitlement will be from the first day of the month in which the veteran died. The veteran's death certificate is evidence
relevant to determining the effective date of any benefits we award.
Aid and attendance or housebound benefits may be available for a veteran's surviving spouse who is unable to perform certain
activities of daily living, are a patient in a nursing home, or are substantially confined to their immediate premises. Special monthly
pension may be effective from the date medical evidence first shows entitlement.

WHERE TO SEND COMPLETED APPLICATION AND EVIDENCE
When you have completed this application, you can either submit online or mail it to the Pension Intake Center listed below. Attach any
materials that support and explain your claim. Also, make a photocopy of your application and any evidence you send to VA before
submitting.
MAIL TO
Department of Veterans Affairs
Pension Intake Center
P.O. Box 5365
Janesville, WI 53547-5365
VA FORM 21P-534EZ, XXX 20XX

SUBMIT ONLINE
VA gov: www.va.gov
Direct Upload via:
access.va.gov
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TERMS AND CALCULATIONS FOR PENSION
Maximum Annual Pension Rate (MAPR)
This is the maximum payable amount of the benefit. Your MAPR is based on how many dependents you have, if you're married to
another Veteran who qualifies for a pension, and if your disabilities qualify you for housebound or aid and attendance benefits. The
MAPR is adjusted each year for cost-of-living increases.
Medical Deductible
The unreimbursed expenses must exceed 5 percent of the applicable MAPR. The deductible increases based on the number of
dependents but is not adjusted for aid and attendance (A&A) or housebound benefits.
Countable Medical Expenses
Your countable medical expenses are only those medical expenses that exceed the Medical Deductible. Medical expenses are
typically considered on a calendar year basis. Your initial year is considered separately, and we will count medical expenses
which provide the greatest benefit.
• Recurring Medical Expenses
o
•
o

Examples include: Medicare Part B, medical related insurance, in-home care provider, or care provided
by a care facility
One-Time Medical Expenses
Examples include: medical co-payments, prescription medications, and durable medical equipment

Reported Annual Medical Expenses - Medical Deductible = Countable Medical Expenses (Min. Zero)
Countable Income
We count the gross income you receive as reported or the income we discover from data matching programs with other federal
sources. If our data match shows a significant discrepancy, you will be asked to clarify the discrepancy. We count incomes in three
ways:
• One-time income is income that you receive once. VA will count it for one year from the first of the following month from
receipt date.
o Examples include: lottery winnings, gifts, capital gains from property sales, irregular IRA (Individual
Retirement Account) or stock disbursements.
• Irregular income is income that you receive at different times or in irregular amounts throughout the year. VA will count it
for one year from the first of the following month from receipt date receipt date.
o Examples include: odd jobs or contract work and interest income.
• Recurring income is counted continuously until we are informed that you are no longer in receipt of it.
o

Examples include: wages from employment, retirement payments, required minimal distributions from an IRA
(Individual Retirement Account).

Income for VA Purposes (IVAP)
VA counts all of your family income and considers any unreimbursed medical expenses reported when determining your IVAP.
The following calculation is a way for you to estimate your IVAP.
Countable Annual Income - Countable Medical Expenses = IVAP
Pension Rate
Your maximum annual benefit is the difference of the current MAPR and what the VA calculates as your IVAP. To convert into a
monthly benefit, take this amount and divide by 12 then rounded down to the nearest dollar.
MAPR - IVAP = Annual Pension Rate
Net Worth
The net worth limit is increased by the same percentage as the Social Security increase when there is a cost-of-living adjustment.
For purposes of entitlement to VA Pension, net worth includes your and your spouse's assets and your and your dependent's
annual income. VA considers children's net worth separately if their net worth would cause you to exceed the limit. VA won't
consider them as a dependent when determining your pension entitlement.
Additional information about how VA calculates net worth, Income, and benefits rates can be found at:
https://www.va.gov/pension/veterans-pension-rates/

VA FORM 21P-534EZ, XXX 20XX

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SURVIVORS BENEFITS APPLICATION CHECKLIST
In addition to your application, VA may require some of the evidence described in this checklist. Failure to provide needed evidence,
may delay the decision on your claim. This checklist does not apply to claims for Accrued benefits. Please carefully read pages 5 and 6
of the Instructions if you are claiming service-connected death (Dependency and Indemnity Compensation (D.I.C.)) only. Please note,
the items marked with an asterisk (*) are required.
VERIFICATION OF VETERAN'S DEATH* (Requested on page 2 of Instructions)
A Death certificate for the veteran, clearly showing the primary cause(s) of death and any contributing factors or conditions (If the veteran's
death certificate lists the cause of death as "Pending," please have the medical examiner submit evidence that shows the cause of death).

SERVICE VERIFICATION* (Requested on page 4 of Instructions and Section III of the form)
Copy of the veteran's DD Form 214 (or equivalent) for all periods of military service. Must demonstrate military service dates, type of service
and character of discharge.

INCOME AND NET WORTH (Requested on page 2 of Instructions and Section IX of the form)
VA Form 21P-0969, Income and Asset Statement in Support of Claim for Pension or Parents' D.I.C., is required if instructed in Section IX of this
application form. NOTE: If you have specific types of income or assets the VA Form 21P-0969 requires additional evidence:
Farm - VA Form 21P-4165, Pension Claim Questionnaire for Farm Income
Business - VA Form 21P-4185, Report of Income from Property or Business
Rental Property - VA Form 21P-4185, Report of Income from Property or Business
Royalties - VA Form 21-4138, Statement in Support of Claim (provide details, such as Royalty source, joint owners, etc.)
Trust - Submit complete Trust documents to include the Schedule of Assets

SPECIAL CIRCUMSTANCES REGARDING YOUR MEDICAL CARE
(Requested on page 2 of Instructions and in Sections VIII and X of the form)
Claim for Special Monthly Pension (SMP) - Aid and Attendance or Housebound Status
VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance
Claim for Medicare Nursing Home and/or $90.00 Rate Reduction Request
VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance
Claim for Fiduciary Assistance
VA Form 21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance
Statement of Medical Care
Care Worksheets (found on pages 19 and 20 of the form)
Proof of Payment from care provided (canceled checks, bank statements, etc.)
Signed verification from care service provider

DEPENDENT CHILDREN* (Requested on page 2 of Instructions and Section VI of the form)
A birth certificate must be included clearly showing the veteran as the parent if you do not reside within the U.S. or its territories. (A state
includes the District of Columbia, Puerto Rico and other territories and possessions of the U.S.)
If child(ren) is/are adopted the adoption decree or a revised birth certificate is required.
If your child is over 18 but under 23 please submit VA Form 21-674, Request for Approval of School Attendance.
Medical records for each seriously disabled child.

MEDICAL EXPENSES (Requested in Section X of the form)
If additional space is needed, submit VA Form 21P-8416, Medical Expense Report.

VA FORM 21P-534EZ, XXX 20XX

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OMB Control No. 2900-0004
Respondent Burden: 40 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR D.I.C., SURVIVORS PENSION,
AND/OR ACCRUED BENEFITS

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 18. Use
this form to submit a claim for D.I.C., Survivors Pension, and/or Accrued Benefits. 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
forms are available at www.va.gov/vaforms. If submitting by mail, send completed form to: Department of
Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION (Must complete)

NOTE: You may either complete the form by typing the information in on the computer or by hand. If completed by hand, print the information requested in ink,
neatly, and legibly to expedite processing of the form.
1A. VETERAN'S NAME (First, Middle Initial, Last)

1C. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)

1B. VETERAN'S SOCIAL SECURITY NUMBER

1D. HAS THE VETERAN, SURVIVING SPOUSE,
CHILD, OR PARENT EVER FILED A CLAIM
WITH VA?
YES

1E. VA FILE NUMBER (If known)

1F. DID THE VETERAN DIE WHILE ON ACTIVE DUTY?
YES

NO

1G. VETERAN'S SERVICE NUMBER

NO

1H. VETERAN'S DATE OF DEATH? (MM/DD/YYYY)

SECTION II: CLAIMANT'S IDENTIFICATION INFORMATION (Must complete)
2A. YOUR NAME (First, Middle Initial, Last)

2B. WHAT IS YOUR RELATIONSHIP TO THE VETERAN? (Check one)
SURVIVING SPOUSE

CHILD 18-23 IN SCHOOL

CUSTODIAN FILING FOR CHILD UNDER 18
2D. YOUR DATE OF BIRTH (MM/DD/YYYY)

2C. YOUR SOCIAL SECURITY NUMBER

HELPLESS ADULT CHILD
2E. ARE YOU A VETERAN?
YES

NO

2F. MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

2G. YOUR TELEPHONE NUMBER (Include Area Code)
International Phone Number (If applicable)
2H. E-MAIL ADDRESS (Optional)

2I. WHAT ARE YOU CLAIMING? (Check all that apply)
DEPENDENCY AND INDEMNITY COMPENSATION (D.I.C.)

SURVIVORS PENSION

ACCRUED BENEFITS

SECTION III: VETERAN'S SERVICE INFORMATION
(Skip to Section IV if the veteran was receiving VA compensation or pension benefits at the time of their death)
NOTE: Please refer to instructions page 4, Military Service Verification for more information pertaining to service information and relevant documents.
3A. DID THE VETERAN SERVE UNDER ANOTHER NAME?
YES

VA FORM
XXX 20XX

NO

(If "YES," list other names the veteran served under below) (First, Middle Initial, Last)

21P-534EZ

SUPERSEDES VA FORM 21P-534EZ, JUL 2022

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION III: VETERAN'S SERVICE INFORMATION (Continued)
3B. DATE VETERAN ENTERED ACTIVE DUTY (MM/DD/YYYY)

3C. DATE VETERAN RELEASED FROM ACTIVE DUTY (MM/DD/YYYY)

3D. BRANCH OF SERVICE
ARMY

3E. PLACE OF LAST SEPARATION

NAVY

AIR FORCE
SPACE FORCE

COAST GUARD

MARINE CORPS
NOAA

USPHS

3F. WAS THE VETERAN ACTIVATED TO FEDERAL/ACTIVE DUTY UNDER AUTHORITY OF TITLE
10, U.S.C. (National Guard)
YES

3G. DATE OF ACTIVATION (MM/DD/YYYY)

(If "NO," skip to Item 3J)

NO

3H. WHAT IS THE NAME OF THE VETERAN'S RESERVE/NATIONAL GUARD UNIT?

3I. WHAT IS THE ADDRESS OF THE VETERAN'S RESERVE/NATIONAL GUARD UNIT?

3J. WHAT IS THE TELEPHONE NUMBER OF THE
RESERVE/NATIONAL GUARD UNIT? (Include Area

Code)

3L. START DATE OF CONFINEMENT

3K. WAS THE VETERAN EVER A PRISONER OF WAR?
YES

(MM/DD/YYYY)

(If "NO," skip to Section IV)

NO

3M. END DATE OF CONFINEMENT

(MM/DD/YYYY)

START:

END:

SECTION IV: MARITAL INFORMATION
(COMPLETE ONLY IF CLAIMING BENEFITS AS THE SURVIVING SPOUSE OF THE VETERAN)
(Skip to Section VI if you are NOT claiming benefits as the surviving spouse of the veteran)
TELL US ABOUT YOUR MARRIAGE TO THE VETERAN
NOTE: When reporting place, if the country is the United States, VA needs city and state as well.

4A. AT THE TIME OF YOUR MARRIAGE TO THE VETERAN, WERE YOU AWARE OF ANY REASON THE MARRIAGE MIGHT NOT BE LEGALLY VALID?
YES

(If "YES," provide explanation below)

NO

4B. WERE YOU MARRIED TO THE VETERAN AT THE TIME
OF HIS/HER DEATH?
YES

4C. HOW DID YOUR MARRIAGE TO THE VETERAN END?
DEATH

DIVORCE

OTHER (Explain)

(If "NO," complete Item 4C)

NO

4D. START DATE OF YOUR MARRIAGE TO THE VETERAN

4F. PLACE OF MARRIAGE (City/State or Country)

4G. PLACE OF MARRIAGE TERMINATION

(City/State or Country)

4E. END DATE OF YOUR MARRIAGE TO THE VETERAN

4H. TYPE OF MARRIAGE (Ceremonial, Common-Law, Proxy, Tribal, etc.)
OTHER (Explain):

CEREMONIAL

4I. WAS A CHILD BORN TO YOU AND THE VETERAN DURING 4J. ARE YOU EXPECTING THE BIRTH OF
THE VETERAN'S CHILD?
YOUR MARRIAGE OR PRIOR TO YOUR MARRIAGE?
YES

YES

NO

4L. WHAT WAS THE REASON FOR SEPARATION?
MEDICAL/FINANCIAL REASONS

NO

4K. DID YOU LIVE CONTINUOUSLY WITH THE
VETERAN FROM THE DATE OF MARRIAGE TO
THE DATE OF HIS/HER DEATH?
YES

NO

(If "YES," skip to Item 4N)

4M. EXPLANATION OF SEPARATION (Give, the reason, date(s), and duration of the separation, to

include the court order if separation is due to court order)

MARITAL DISCORD/OTHER (if you select this option
fill out 4M)

TELL US ABOUT YOUR REMARRIAGE AFTER THE VETERAN'S DEATH
4N. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?
YES

NO

4O. START DATE OF YOUR REMARRIAGE? (MM/DD/YYYY)

(If "NO," skip to Item 5A)
4P. END DATE OF YOUR REMARRIAGE? (MM/DD/YYYY)

4Q. HOW DID YOUR REMARRIAGE END?
DEATH

DIVORCE

DID NOT END

OTHER (Explain)

4R. DID YOU HAVE ADDITIONAL MARRIAGES AFTER THE VETERAN'S DEATH?
YES

NO

(If "YES," please submit a VA Form 21-4138, Statement in Support of Claim, as needed to provide the information for each marriage)

VA FORM 21P-534EZ, XXX 20XX

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION V: MARITAL HISTORY
NOTE: When reporting place, if the country is the United States, VA needs city and state as well.
5A. WERE YOU RECOGNIZED AS THE SPOUSE BY VA BEFORE THE DEATH OF THE VETERAN OR WERE YOU AND THE VETERAN ONLY EVER MARRIED TO
EACH OTHER? IF YES, SKIP TO SECTION VI.
YES

NO

VETERAN'S PRIOR MARRIAGES (If None, skip to Item 5O)
5B. NAME OF PERSON VETERAN WAS PREVIOUSLY MARRIED TO (First, Middle Initial, Last)

5C. HOW DID THE VETERAN'S PREVIOUS MARRIAGE END?
DEATH

DIVORCE

OTHER (Explain)

5D. DATE OF VETERAN'S PREVIOUS
START:
MARRIAGE? (MM/DD/YYYY)
5E. DATE OF VETERAN'S PREVIOUS
MARRIAGE? (MM/DD/YYYY)

5F. PLACE OF MARRIAGE (City/State or Country)

END:

5G. PLACE OF MARRIAGE TERMINATION (City/State or Country)

5H. NAME OF PERSON VETERAN WAS PREVIOUSLY MARRIED TO (First, Middle Initial, Last)

5I. HOW DID THE VETERAN'S PREVIOUS MARRIAGE END?
DEATH

DIVORCE

OTHER (Explain)

5J. DATE OF VETERAN'S PREVIOUS
MARRIAGE? (MM/DD/YYYY)

START:

5K. DATE OF VETERAN'S PREVIOUS
MARRIAGE? (MM/DD/YYYY)

END:

5L. PLACE OF MARRIAGE (City/State or Country)

5M. PLACE OF MARRIAGE TERMINATION (City/State or Country)

5N. DO YOU HAVE ADDITIONAL MARRIAGES TO REPORT FOR THE VETERAN?
YES

NO

(If "YES," please submit a VA Form 21-686c, Application to Request to Add And/Or Remove Dependents, or VA Form 21-4138, Statement
in Support of Claim, as needed to provide the information for additional marital history)

TELL US ABOUT YOUR MARRIAGES PRIOR TO MARRYING THE VETERAN (If None, skip to Section VI)
5O. NAME OF PERSON YOU WERE MARRIED TO PRIOR TO MARRYING THE VETERAN (First, Middle Initial, Last)

5P. HOW DID YOUR PREVIOUS MARRIAGE END?
DEATH

DIVORCE

OTHER (Explain)

5Q. DATE OF YOUR PREVIOUS
MARRIAGE? (MM/DD/YYYY)

START:

5R. DATE OF YOUR PREVIOUS
END:
MARRIAGE? (MM/DD/YYYY)
5S. PLACE OF MARRIAGE (City/State or Country)

5T. PLACE OF MARRIAGE TERMINATION (City/State or Country)

5U. NAME OF PERSON YOU WERE MARRIED TO PRIOR TO MARRYING THE VETERAN (First, Middle Initial, Last)

5V. HOW DID YOUR PREVIOUS MARRIAGE END?
DEATH

DIVORCE

OTHER (Explain)

5W. DATE OF VETERAN'S PREVIOUS
START:
MARRIAGE? (MM/DD/YYYY)
5X. DATE OF VETERAN'S PREVIOUS
MARRIAGE? (MM/DD/YYYY)

5Y. PLACE OF MARRIAGE (City/State or Country)

END:

5Z. PLACE OF MARRIAGE TERMINATION (City/State or Country)

5. DO YOU HAVE ADDITIONAL MARRIAGES TO REPORT?
YES

NO

(If "YES," please submit a VA Form 21-686c, Application to Request to Add And/Or Remove Dependents, or VA Form 21-4138, Statement
in Support of Claim, as needed to provide the information for additional marital history)

VA FORM 21P-534EZ, XXX 20XX

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION VI: CHILD OF THE VETERAN INFORMATION
(COMPLETE ONLY IF CLAIMING BENEFITS FOR A CHILD(REN) OF THE VETERAN)
(Skip to Section VII if you are NOT claiming benefits for a child(ren) of the veteran)

NOTE: Please refer to instructions page 2, under "Special Circumstances" for what is considered a dependent child. In most circumstances, children over the age
of 23 are not considered dependent for VA purposes, unless the child is determined to be seriously disabled based on a condition that started before turning 18.
NOTE: When reporting place, if the country is the United States, VA needs city and state as well.
6A. HOW MANY DEPENDENT CHILDREN OF THE VETERAN ARE THERE?

(NOTE: Please complete a VA Form 21-686c, Application Request to Add and/or Remove Dependents, if you need more space for additional dependents.)
6B. CHILD'S NAME (First, Middle Initial, Last)

6C. CHILD'S BIRTH DATE (MM/DD/YYYY)

6D. CHILD'S SOCIAL SECURITY NUMBER

6E. PLACE OF BIRTH (City/State or Country)
6F. WHAT IS THE CHILD'S STATUS? (Select all that apply)
ADOPTED
STEPCHILD
BIOLOGICAL
18-23 YEARS OLD (in school)

SERIOUSLY DISABLED

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

MARRIED/PREVIOUSLY MARRIED

$

6G. CHILD'S NAME (First, Middle Initial, Last)

6H. CHILD'S BIRTH DATE (MM/DD/YYYY)

6I. CHILD'S SOCIAL SECURITY NUMBER

6J. PLACE OF BIRTH (City/State or Country)

6K. WHAT IS THE CHILD'S STATUS? (Select all that apply)
BIOLOGICAL

ADOPTED

18-23 YEARS OLD (in school)

STEPCHILD

SERIOUSLY DISABLED

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

MARRIED/PREVIOUSLY MARRIED

$

6L. CHILD'S NAME (First, Middle Initial, Last)

6M. CHILD'S BIRTH DATE (MM/DD/YYYY)

6N. CHILD'S SOCIAL SECURITY NUMBER

6O. PLACE OF BIRTH (City/State or Country)

6P. WHAT IS THE CHILD'S STATUS? (Select all that apply)
BIOLOGICAL

ADOPTED

STEPCHILD

18-23 YEARS OLD (in school)

SERIOUSLY DISABLED

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

MARRIED/PREVIOUSLY MARRIED

$

6Q. DO YOUR CHILDREN WHO DO NOT LIVE WITH YOU (If listed above) RESIDE AT THE SAME ADDRESS?
YES

NO

(If "YES," please complete Item 6R) (If “NO,” Please complete a VA Form 21-4138, Statement in Support of Claim, with the following information:
Name of person the child is currently living with, and the full address of where the child resides.)

6R. PLEASE PROVIDE THE NAME OF THE CHILD(RENS) CUSTODIAN BELOW:
NAME OF CUSTODIAN (First, Middle Initial, Last)

6S. PLEASE PROVIDE THE ADDRESS OF THE CHILD(RENS) CUSTODIAN BELOW:
MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number
State/Province

VA FORM 21P-534EZ, XXX 20XX

City
Country

ZIP Code/Postal Code

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION VII: DEPENDENCY AND INDEMNITY COMPENSATION (D.I.C.)
(Skip to Section VIII if you are NOT claiming D.I.C.)
7A. WHAT BENEFIT ARE YOU CLAIMING? (Check one) Please refer to the Instructions page 5 for guidance on 38 U.S.C. 1151)

(Note: Please refer to Instructions page 6 for guidance on PACT Act)

D.I.C. under U.S.C. 1151 (Note: D.I.C. under 38 U.S.C. is a rare

D.I.C.

benefit.)

D.I.C. due to claimant election of a re-evaluation of a previously denied claim
based on expanded eligibility under PL 117-168 (PACT Act)

7B. LIST ANY VA MEDICAL CENTERS WHERE THE VETERAN RECEIVED TREATMENT PERTAINING TO YOUR CLAIM AND PROVIDE TREATMENT DATES
NAME OF VA MEDICAL CENTER

LOCATION

START DATE(S) OF TREATMENT

(MM/DD/YYYY)

END DATE(S) OF TREATMENT

(MM/DD/YYYY)

SECTION VIII: NURSING HOME OR INCREASED SURVIVORS ENTITLEMENT
8A. ARE YOU CLAIMING SPECIAL MONTHLY PENSION OR SPECIAL MONTHLY D.I.C. BECAUSE YOU NEED THE REGULAR ASSISTANCE OF ANOTHER
PERSON, HAVE SEVERE VISUAL PROBLEMS, OR ARE GENERALLY CONFINED TO YOUR IMMEDIATE PREMISES?
YES

NO

(If "YES," please complete a VA Form 21-2680, Examination 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/CRNP), or
Clinical Nurse Specialist (CNS))

8B. ARE YOU NOW IN A NURSING HOME?
YES

NO

(If "YES," complete VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid and Attendance. For additional
information see Instructions, page 6 under "Increased Survivor Benefits Based on Special Monthly Pension or Special Monthly D.I.C.")

SECTION IX: INCOME AND ASSETS
(Skip to Section X if you are NOT claiming survivors pension but claiming any last expenses)
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.
IMPORTANT:
• If you are a surviving spouse claimant, you must report income and assets for yourself and for any child of the veteran who lives with you or for whom you are
responsible unless a court has decided you do not have custody of the child.
• If you are a surviving child claimant (which means the child is not in the custody of a surviving spouse), you must report income and assets for yourself, your
custodian, and your custodian's spouse.
9A. DO YOU OR YOUR DEPENDENTS HAVE OVER $75,000.00 IN ASSETS (NOT INCLUDING THE VALUE OF YOUR PRIMARY RESIDENCE)?
YES

NO

(If “YES,” please submit VA Form 21P-0969, Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and
Indemnity Compensation (D.I.C.))
(If "No," provide an estimate of the total value of your assets below)

$

9B. IN THE THREE CALENDAR YEARS BEFORE THIS YEAR, DID YOU OR YOUR DEPENDENTS TRANSFER ANY ASSETS? (Examples of asset transfers include

giving assets away, selling assets, purchasing an annuity, or using assets to establish a trust.)
YES

NO

(If “YES,” please submit VA Form 21P-0969, Income and Asset Statement in Support of Claim for Pension or Parents' Dependency and
Indemnity Compensation (D.I.C.))

9C. DO YOU OR YOUR DEPENDENTS OWN YOUR/YOUR FAMILY'S PRIMARY
RESIDENCE?
YES

NO

(If “NO,” skip to Item 9G)

9E. IF PRIMARY RESIDENCE SITS ON A LOT OVER 2 ACRES (87,120 SQ FT),
WHAT IS THE VALUE OF LAND OVER 2 ACRES? (Do NOT include the

value of the residence or the first 2 acres.)

9D. IS THE LOT ON WHICH THE PRIMARY RESIDENCE SITS OVER 2 ACRES
(87,120 SQ FT)?
YES

NO

(If “NO,” skip to Item 9G)

9F. IS THE LAND OVER 2 ACRES (87, 120 SQ FT) MARKETABLE?
YES

NO

(If “YES,” please submit VA Form 21P-0969)

$
9G. HOW MANY INCOME SOURCES DOES YOUR FAMILY HAVE?
NO INCOME

1-4 SOURCES OF INCOME

5+ SOURCES OF INCOME
VA FORM 21P-534EZ, XXX 20XX

(If 5+ please submit VA Form 21P-0969) and
ONLY report your Social Security Income)

9H. OTHER THAN SOCIAL SECURITY, DID YOU OR YOUR DEPENDENTS
RECEIVE ANY INCOME LAST YEAR THAT YOU NO LONGER RECEIVE?
YES

NO

(If "YES," please submit VA Form 21P-0969)
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VETERAN'S SOCIAL SECURITY NUMBER

SECTION IX: INCOME AND ASSETS (Continued)
(Skip to Section X if you are NOT claiming survivors pension but claiming any last expenses)
Please use the space below to report any income you currently receive.
IMPORTANT: If you have been directed to complete a VA Form 21P-0969, Income and Asset Statement in Support of Claim for Pension or Parents' D.I.C., in
previous Items 9A through 9H, VA only requires that Social Security income be reported below in Items 9I through 9L. All other income should be reported on the
VA Form 21P-0969 and will be counted as reported, do not duplicate.
NOTE: Gross income is defined as any income you received prior to deductions. If reporting income in Items 9I through 9L, any items skipped or left blank will be
considered as unspecified income and could require a request for additional information potentially delaying your claim. If you leave entire question blank we will
assume you have no income to report.
9I(1) WHO IS THE INCOME RECIPIENT? (Select one)
SURVIVING SPOUSE

CUSTODIAN

CHILD (Specify Name)
CUSTODIAN'S SPOUSE

9I(3) SPECIFY INCOME PAYER (Name of
business, financial institution, etc.)

9I(2) SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

INTEREST/DIVIDENDS

CIVIL SERVICE

PENSION/RETIREMENT

9I(4) CURRENT GROSS MONTHLY INCOME

OTHER (Specify type of income)
$

9J(1) WHO IS THE INCOME RECIPIENT? (Select one)
SURVIVING SPOUSE

CUSTODIAN

9J(3) SPECIFY INCOME PAYER (Name of
business, financial institution, etc.)

9J(2) SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

INTEREST/DIVIDENDS

CHILD (Specify Name)

CIVIL SERVICE

PENSION/RETIREMENT

CUSTODIAN'S SPOUSE

OTHER (Specify type of income)

9K(1) WHO IS THE INCOME RECIPIENT? (Select one)
SURVIVING SPOUSE

CUSTODIAN

9J(4) CURRENT GROSS MONTHLY INCOME
$
9K(3) SPECIFY INCOME PAYER (Name of
business, financial institution, etc.)

9K(2) SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

INTEREST/DIVIDENDS

CHILD (Specify Name)

CIVIL SERVICE

PENSION/RETIREMENT

CUSTODIAN'S SPOUSE

OTHER (Specify type of income)

9K(4) CURRENT GROSS MONTHLY INCOME
$

9L(1) WHO IS THE INCOME RECIPIENT? (Select one)
SURVIVING SPOUSE

CUSTODIAN

9L(3) SPECIFY INCOME PAYER (Name of
business, financial institution, etc.)

9L(2) SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

INTEREST/DIVIDENDS

CHILD (Specify Name)

CIVIL SERVICE

PENSION/RETIREMENT

CUSTODIAN'S SPOUSE

OTHER (Specify type of income)

9L(4) CURRENT GROSS MONTHLY INCOME
$

SECTION X: INFORMATION ABOUT YOUR MEDICAL OR OTHER 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 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, 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 were/will be reimbursed.
Please make sure to complete all criteria below (if applicable). If you need more space, complete and attach a separate VA Form 21P-8416, Medical Expense Report.
IMPORTANT: Out of pocket expenses paid by you or a VA-approved dependent may be claimed. Do NOT include expenses paid by other family members,
insurance, etc.
10A. ARE YOU OR YOUR DEPENDENTS CLAIMING UNREIMBURSED MEDICAL EXPENSES OR OTHER EXPENSES?
YES

NO

(If “NO,” skip to Section XI)

IN-HOME CARE OR CARE FACILITY
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 19 and 20 for each provider. All in-home care fees or facility fees you pay must be reported on this form if you want VA to use them as a deductible
expense.
10B(1). WHOSE EXPENSES WERE PAID?

(Select one)

SURVIVING SPOUSE

10B(4). IF THIS IS AN IN-HOME CARE
PROVIDER WHAT IS THE:
Payment Rate $
.00
(Per Hour)

10B(2). NAME OF PROVIDER

10B(3). TYPE OF CARE

OTHER (Specify Name)

10B(6). PROVIDER START
DATE (MM/DD/YYYY)

CHECK ONE:

NURSING HOME

RESIDENTIAL CARE FACILITY

ADULT DAYCARE

IN-HOME CARE ATTENDANT

10B(5). IF THIS IS AN IN-HOME CARE
PROVIDER WHAT IS THE:
Hours Worked
(Per Month)

10B(8). PAYMENT FREQUENCY
MONTHLY

10B(7). PROVIDER END DATE

ANNUALLY

10B(9). AMOUNT YOU PAY (Based on

frequency selected in Item 10B(5))

$

(MM/DD/YYYY)

CONTINUING
VA FORM 21P-534EZ, XXX 20XX

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VETERAN'S SOCIAL SECURITY NUMBER

IN-HOME CARE OR CARE FACILITY (Continued)
10C(1). WHOSE EXPENSES WERE PAID?

(Select one)

SURVIVING SPOUSE

10C(4). IF THIS IS AN IN-HOME CARE
PROVIDER WHAT IS THE:
Payment Rate $
.00
(Per Hour)

10C(2). NAME OF PROVIDER
10C(3). TYPE OF CARE

OTHER (Specify Name)

CHECK ONE:

NURSING HOME

RESIDENTIAL CARE FACILITY

ADULT DAYCARE

IN-HOME CARE ATTENDANT

10C(6). PROVIDER START
DATE (MM/DD/YYYY)

10C(5). IF THIS IS AN IN-HOME CARE
PROVIDER WHAT IS THE:
Hours Worked
(Per Month)

10C(8). PAYMENT FREQUENCY
MONTHLY

10C(9). AMOUNT YOU PAY (Based on

frequency selected in Item 10C(5))

ANNUALLY

10C(7). PROVIDER END DATE

$

(MM/DD/YYYY)

CONTINUING
10D(1). WHOSE EXPENSES WERE PAID?

(Select one)

SURVIVING SPOUSE

10D(2). NAME OF PROVIDER
10D(3). TYPE OF CARE

OTHER (Specify Name)

10D(4). IF THIS IS AN IN-HOME CARE
PROVIDER WHAT IS THE:
Payment Rate
(Per Hour)

CHECK ONE:

NURSING HOME

RESIDENTIAL CARE FACILITY

ADULT DAYCARE

IN-HOME CARE ATTENDANT

$

.00

10C(5). IF THIS IS AN IN-HOME CARE
PROVIDER WHAT IS THE:
Hours Worked
(Per Month)

10D(6). PROVIDER START
DATE (MM/DD/YYYY)

10D(8). PAYMENT FREQUENCY
MONTHLY

10D(7). PROVIDER END DATE

ANNUALLY

10D(9). AMOUNT YOU PAY (Based on

frequency selected in Item 10D(5))

$

(MM/DD/YYYY)

CONTINUING

OTHER MEDICAL, LAST, AND/OR BURIAL EXPENSES
10E(1). WHOSE EXPENSES WERE PAID?

10E(2). PAID TO (Name of Provider, Insurance company, etc.)

(Select one)

SURVIVING SPOUSE
VETERAN (Last expense/burial)
CHILD (Specify Name)
10E(4). DATE COSTS PAID (MM/DD/YYYY)

10E(3). PURPOSE (Any medical insurance premium, medical supplies, etc.)

10E(5). PAYMENT FREQUENCY
MONTHLY

selected in Item 10E(4))

$

ONE-TIME

10F(1). WHOSE EXPENSES WERE PAID?

10E(6). AMOUNT YOU PAY (Based on frequency

ANNUALLY

10E(2). PAID TO (Name of Provider, Insurance company, etc.)

(Select one)

SURVIVING SPOUSE
VETERAN (Last expense/burial)
CHILD (Specify Name)
10F(4). DATE COSTS PAID (MM/DD/YYYY)

10E(3). PURPOSE (Any medical insurance premium, medical supplies, etc.)

10F(5). PAYMENT FREQUENCY
MONTHLY

(Select one)

selected in Item 10F(4))

$

ONE-TIME

10G(1). WHOSE EXPENSES WERE PAID?

10F(6). AMOUNT YOU PAY (Based on frequency

ANNUALLY

10G(2). PAID TO (Name of Provider, Insurance company, etc.)

SURVIVING SPOUSE
VETERAN (Last expense/burial)
CHILD (Specify Name)
10G(4). DATE COSTS PAID (MM/DD/YYYY)

10G(3). PURPOSE (Any medical insurance premium, medical supplies, etc.)

10G(5). PAYMENT FREQUENCY
MONTHLY
ONE-TIME

VA FORM 21P-534EZ, XXX 20XX

10G(6). AMOUNT YOU PAY (Based on

frequency selected in Item 10G(4))

ANNUALLY

$
Page 16

VETERAN'S SOCIAL SECURITY NUMBER

OTHER MEDICAL, LAST AND/OR BURIAL EXPENSES (Continued)
10E(2). PAID TO (Name of Provider, Insurance company, etc.)
10H(1). WHOSE EXPENSES WERE PAID?
(Select one)
SURVIVING SPOUSE
VETERAN (Last expense/burial)

10E(3). PURPOSE (Any medical insurance premium, medical supplies, etc.)

CHILD (Specify Name)
10H(4). DATE COSTS PAID (MM/DD/YYYY)

10H(5). PAYMENT FREQUENCY
MONTHLY

10H(6). AMOUNT YOU PAY (Based on

frequency selected in Item 10H(4))

ANNUALLY

$

ONE-TIME

10I(1). WHOSE EXPENSES WERE PAID?

(Select one)

10I(2). PAID TO (Name of Provider, Insurance company, etc.)

SURVIVING SPOUSE
VETERAN (Last expense/burial)

10I(3). PURPOSE (Any medical insurance premium, medical supplies, etc.)

CHILD (Specify Name)
10I(4). DATE COSTS PAID (MM/DD/YYYY)

10I(5). PAYMENT FREQUENCY
MONTHLY

10I(6). AMOUNT YOU PAY (Based on frequency

$

ONE-TIME

10J(1). WHOSE EXPENSES WERE PAID?

(Select one)

selected in Item 10I(4))

ANNUALLY

10J(2). PAID TO (Name of Provider, any medical Insurance company, etc.)

SURVIVING SPOUSE
VETERAN (Last expense/burial)

10J(3). PURPOSE (Any medical insurance premium, medical supplies, etc.)

CHILD (Specify Name)

10J(3). DATE COSTS PAID (MM/DD/YYYY)

10J(4). PAYMENT FREQUENCY
MONTHLY

10J(5). AMOUNT YOU PAY (Based on frequency

selected in Item 10J(4))

ANNUALLY

ONE-TIME

$

SECTION XI: DIRECT DEPOSIT INFORMATION (MUST COMPLETE)
The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in direct
deposit, provide the information requested below. 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 the Treasury at 1-888-224-2950. They
will encourage your participation in EFT and address questions or concerns you may have.
11A. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank where you

want your direct deposit)

11B. ROUTING OR TRANSIT NUMBER (The first nine numbers

located at the bottom left of your check)

11C. 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

I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL INSTITUTION OR CERTIFIED PAYMENT AGENT

Account No.:

SECTION XII: 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 except protected health information, and I waive any privilege which makes the information confidential.
I certify I have received the notice attached to this application titled Notice to Survivor of Evidence Necessary to Substantiate a Claim for Dependency and
Indemnity Compensation, Survivors Death Pension, and/or Accrued 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.

VA FORM 21P-534EZ, XXX 20XX

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VETERAN'S SOCIAL SECURITY NUMBER

SECTION XII: CLAIM CERTIFICATION AND SIGNATURE (MUST COMPLETE) (Continued)
12B. CLAIMANT'S SIGNATURE OR MARK WITH AN "X" IF UNABLE TO SIGN (REQUIRED)

12C. DATE SIGNED (MM/DD/YYYY)

SECTION XIII: WITNESSES TO SIGNATURE

(TWO (2) WITNESS SIGNATURES ARE REQUIRED ONLY IF ITEM 12B IS SIGNED WITH AN "X")
13A. SIGNATURE OF WITNESS (Sign in INK) (NOTE: Only sign if claimant signed

in Item 12B using an "X")

13B. PRINTED NAME OF FIRST WITNESS
Name:
13C. PRINTED ADDRESS OF FIRST WITNESS
Address:

13C. SIGNATURE OF WITNESS (Sign in INK) (NOTE: Only sign if claimant signed

in Item 12B using an "X")

13D. PRINTED NAME OF SECOND WITNESS
Name:
13E. PRINTED ADDRESS OF SECOND WITNESS
Address:

SECTION XIV: ALTERNATE SIGNER CERTIFICATION AND SIGNATURE (NOTE: REQUIRED ONLY IF ITEM 12B IS BLANK)
I certify that by signing on behalf of the claimant, that I am a court-appointed representative; OR, an attorney in fact or agent authorized to act on behalf
of a claimant under a durable power of attorney; OR, a person who is responsible for the care of the claimant, to include but not limited to a spouse or
other relative; OR, a manager or principal officer acting on behalf of an institution which is responsible for the care of an individual; AND, that the
claimant is under the age of 18; OR, is mentally incompetent to provide substantially accurate information needed to complete the form, or to certify that
the statements made on the form are true and complete; OR, is physically unable to sign this form.
I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury. I also understand that
VA may request further documentation or evidence to verify or confirm my authorization to sign or complete an application on behalf of the claimant if
necessary. Examples of evidence which VA may request include: Social Security Number (SSN) or Taxpayer Identification Number (TIN); a certificate
or order from a court with competent jurisdiction showing your authority to act for the claimant with a judge's signature and a date/time stamp; copy of
documentation showing appointment of fiduciary; durable power of attorney showing the name and signature of the claimant and your authority as
attorney in fact or agent; health care power of attorney, affidavit or notarized statement from an institution or person responsible for the care of the
claimant indicating the capacity or responsibility of care provided; or any other documentation showing such authorization.
14A. ALTERNATE SIGNER SIGNATURE

14B. DATE SIGNED (MM/DD/YYYY)

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 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 Veteran
Readiness 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, 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays

a currently valid OMB control number. The OMB control number for this project is 2900-0004, and it expires XX/XX/20XX. Public reporting burden for
this collection of information is estimated to average 40 minutes per respondent, per year, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at
[email protected]. Pleaserefer to OMB Control No. 2900-0004 in any correspondence. Do not send your completed VA Form 21P-534EZ to this email
address.

VA FORM 21P-534EZ, XXX 20XX

Page 18

WORKSHEET FOR A RESIDENTIAL CARE, ADULT DAYCARE, OR A SIMILAR FACILITY
NOTE: This worksheet is to be completed by an administrator or licensed medical professional from a residential care, adult daycare, or similar facility. To count
this medical provider as an expense, they must be claimed on your application for benefits or VA Form 21P-8416, Medical Expense Report. In addition, VA Form
21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance may be needed to count these expenses.
1. WHO ARE YOU COMPLETING THIS WORKSHEET FOR? (Name of Care Recipient, either the Claimant or Dependent) (First, Last)

2. WHO IS COMPLETING THIS WORKSHEET? (Name of Provider, either an Administrator or Licensed Medical Professional) (First, Last)

3. WHAT ROLE OR POSITION DO YOU PERFORM AT THE FACILITY?

4. WHAT IS THE NAME OF THE FACILITY? (As shown on facility license or official website)

5. WHAT IS THE FACILITY TELEPHONE NUMBER?

International Phone Number (If applicable)

6. WHAT IS THE MAILING ADDRESS OF THE FACILITY OR THE FACILITY'S ADMINISTRATIVE OFFICE?
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code

7. WHAT IS THE FACILITY'S WEBSITE ADDRESS?

8. SELECT EACH ACTIVITY OF DAILY LIVING (ADL) THAT THE FACILITY IS PROVIDING TO THE CARE RECIPIENT.
A. EATING

B. BATHING/SHOWERING

C. TRANSFERRING IN OR OUT OF BED OR CHAIR

D. DRESSING

E. USING THE TOILET

F. AMBULATING WITHIN HOME OR LIVING AREA

9. FOR EACH STATEMENT BELOW PLEASE CHECK THE BOX IF THIS STATEMENT IS TRUE FOR THE FACILITY:
YES

NO
THE STATE OR COUNTRY REQUIRES THIS FACILITY TO BE LICENSED
THE FACILITY IS LICENSED
THE FACILITY IS RESIDENTIAL
THE FACILITY IS STAFFED 24 HOURS

10. DOES THE FACILITY'S STAFF PROVIDE THE CARE RECIPIENT WITH HEALTH CARE OR CUSTODIAL CARE OR BOTH.

(Custodial Care is regular assistance with two or more ADLs (Question 8), or supervision because an individual with a physical, mental, developmental, or
cognitive disorder requires care or assistance on a regular basis to protect the individual from hazards or dangers incident to their daily environment.)
YES

NO, Care is being provided by a third-party provider.

NO, Care is not being provided to this claimant.

If care is provided by a third-party provider, please ensure the claimant has each In-Home provider complete an In-Home Attendant Worksheet.
12. DO YOU EXPECT THIS CARE TO END? (If "Yes, "provide the date the care is
11. DATE THE CARE RECIPIENT WAS ADMITTED TO THE FACILITY.

expected to end in question 13.)

(MM/DD/YYYY)

YES

NO

13. DATE YOU EXPECT CARE TO END. (MM/DD/YYYY)

14. MONTHLY CHARGES THE CARE RECIPIENT STAYING AT THE FACILITY IS RESPONSIBLE FOR PAYING.
$

,

.

PER MONTH

FACILITY CERTIFICATION
I CERTIFY that the information stated within this WORKSHEET FOR AN ASSISTED LIVING, ADULT DAYCARE, OR SIMILAR FACILITY is accurate and
reflects the current environment of the Care Recipient and the facility.
14. SIGNATURE OF PROVIDER (From question 2)

VA FORM 21P-534EZ, XXX 20XX

15. DATE SIGNED (MM/DD/YYYY)

Page 19

WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
NOTE: This worksheet is to be completed by your in-home care provider -OR- if an agency is providing you in-home care please have an agency administrator
complete this form. These expenses must be claimed on your application for benefits or VA Form 21P-8416, Medical Expense Report. In addition, VA Form
21-2680, Examination for Housebound Status or Permanent Need for Regular Aid and Attendance may be needed to count these expenses.
1. WHO ARE YOU COMPLETING THIS WORKSHEET FOR? (Name of Care Recipient, either the Claimant or Dependent) (First, Last)

2. WHO IS COMPLETING THIS WORKSHEET? (In-Home Care Attendant or Agency Administrator, Provider) (First, Last)

3. IS THE IN-HOME CARE PROVIDED BY A LICENSED MEDICAL PROFESSIONAL?

4. DO YOU WORK FOR AN AGENCY OR
ORGANIZATION?

(A licensed health care provider refers to a person licensed to furnish health services by the State or
country in which the services are provided.)
YES

YES

NO

5. WHAT IS THE NAME OF THE AGENCY OR ORGANIZATION?

NO (If "NO," skip to question 7)

6. WHAT IS THE AGENCY TELEPHONE NUMBER?

7. WHAT IS YOUR MAILING ADDRESS OR THAT OF YOUR AGENCY'S ADMINISTRATIVE OFFICE?
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code

8. PLEASE SELECT EACH ACTIVITY OF DAILY LIVING (ADL) THAT THE IN-HOME CARE ASSISTANT PROVIDED TO THE CARE RECIPIENT.
A. EATING

B. BATHING/SHOWERING

C. TRANSFERRING IN OR OUT OF BED OR CHAIR

D. DRESSING

E. USING THE TOILET

F. AMBULATING WITHIN HOME OR LIVING AREA

9. PLEASE SELECT EACH INSTRUMENTAL ACTIVITY OF DAILY LIVING (IADL) THAT THE IN-HOME CARE ASSISTANT PROVIDES TO THE CARE RECIPIENT.
A.SHOPPING

B. FOOD PREPARATION

C. NON-MEDICAL TRANSPORTATION

D. LAUNDERING

E. USING TELEPHONE

F. MANAGING FINANCES

G. HOUSEKEEPING

H. HANDLING MEDICATIONS

10. IS THE PRIMARY RESPONSIBILITY OF THE IN-HOME ATTENDANT TO PROVIDE THE CARE RECIPIENT WITH HEALTH CARE OR CUSTODIAL CARE?

(Custodial Care is regular assistance with two or more ADLs (Question 8), or supervision because an individual with a physical, mental, developmental, or
cognitive disorder requires care or assistance on a regular basis to protect the individual from hazards or dangers incident to their daily environment.)
YES

NO

11. PLEASE PROVIDE THE DATE CARE BEGAN FOR THE CARE RECIPIENT.

(MM/DD/YYYY)

12. DO YOU EXPECT THIS CARE TO END? (IF YES, PROVIDE THE DATE THE
CARE IS EXPECTED TO END IN QUESTION 13.)
YES

NO

13. DATE YOU EXPECT THIS CARE TO END? (MM/DD/YYYY)

14. MONTHLY CHARGES THE CARE RECIPIENT IS RESPONSIBLE FOR
PAYING.
$

.

15. PLEASE PROVIDE THE TOTAL HOURS PER MONTH THAT YOU PROVIDE
CARE TO THE CARE RECIPIENT.

PER HOUR

HOURS PER MONTH

CERTIFICATION
I CERTIFY that the information stated within this WORKSHEET FOR IN-HOME ATTENDANT EXPENSES is accurate and reflects the current environment of
the care recipient and the care services listed in questions eight and nine (8-9) above.
15. SIGNATURE OF PROVIDER (From question 2)

VA FORM 21P-534EZ, XXX 20XX

16. DATE SIGNED (MM/DD/YYYY)

Page 20