VA Form 21P-0969

Status: Original and derived artifacts are available for this document.

Download: pdf

INCOME AND ASSET STATEMENT IN SUPPORT OF CLAIM FOR PENSION OR
PARENTS' 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 income and assets for:
• Yourself
• Your spouse (unless you live apart, and you are estranged, and you do not contribute to your spouse's support)
• Your child or children (unless you do not have custody,* and you do not contribute to your child's or children's support)
If you are a Surviving Spouse, you must report income and assets for:
• Yourself
• Your child or children (unless you do not have custody,* and you do not contribute to your child's or children's support)
If you are a Surviving 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
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.)
* 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.
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: INCOME AND NET WORTH ASSOCIATED WITH
OWNED ASSETS
SECTION VI: INCOME AND NET WORTH ASSOCIATED WITH
ROYALTIES AND OTHER PROPERTIES

VA FORM 21P-0969, XXX 20XX

SECTION VII: ASSET TRANSFERS
SECTION VIII: TRUSTS
SECTION IX: ANNUITIES
SECTION X: ASSETS PREVIOUSLY NOT
REPORTED
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 (Pension received from the Philippine Veterans Affairs
• Social Security Income
• Railroad Retirement Benefits
Office (PVAO) is reportable income for VA Pension)
• Civil Service Retirement
• Wages
• Military Retirement
• Black Lung Benefits
• Unemployment 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
• Interest Earning Accounts (Checking, Savings, etc)
• Stocks and Dividends
• Individual Retirement Account (IRA) Distributions (Including RMDs)
• Annuities
• 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
Additional documentation may be required for each of the following income sources:

• Business Earnings

• 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 demonstrating the sell-ability, 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 you have more than one trust to report, submit the information on a separate VA Form 21P-0969
or provide the information on VA Form 21-4138 for each additional trust established. Provide the following additional evidence for each trust:
• Initial contract from your financial institution establishing the trust
• Current statement showing surrender value and monthly payments
• Schedule of Assets must be included
SECTION IX: ANNUITY
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 establishing the annuity
• Current statement showing surrender value and monthly payments
SECTION X: ASSETS PREVIOUSLY NOT PREPORTED
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 2E. 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
• Irregular - Income received several times during the reporting period at
irregular intervals or irregular amounts
• One-Time - Income that only occurred once
VA FORM 21P-0969, XXX 20XX

Page 2

SECTION XII: WAIVER OF RECEIPT OF INCOME
Waived income, or income you are entitled to receive but have chosen not to accept at this time is considered countable income for VA pension
purposes. It is unlawful to waive of entitlement of any income to create a need for pension. Examples include:
• Deferred Compensation
• Life Insurance
• Legal Settlements

EXCEPTION: Waiving income from the Social Security Administration done so to get a higher amount of SSA by waiting longer is allowed.
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-of-attorney 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: 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 2900-0829, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 30 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]. Please refer to OMB Control No. 2900-0829 in any correspondence. Do not send your completed VA Form 21P-0969 to this email address.

VA FORM 21P-0969, XXX 20XX

Page 3

OMB Control No. 2900-0829
Respondent Burden: 30 minutes
Expiration Date: XX/XX/20XX

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

1B. VETERAN'S SOCIAL SECURITY NUMBER

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

2B. CLAIMANT'S SOCIAL SECURITY NUMBER
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 earliest of the following dates:
• 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 REPRESENTS INCOME AND NET WORTH FOR THE FOLLOWING PERIOD ((MM/DD/YYYY) THROUGH (MM/DD/YYYY)):
THROUGH

DATE RECEIVED BY VA (For initial claims only.)

-OR-

SECTION III: RECURRING INCOME NOT ASSOCIATED WITH ACCOUNTS OR ASSETS

(See instructions on Page 2)

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if

Custodian of child, child, parent, or other)

CHILD

(4). GROSS MONTHLY INCOME

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

RETIREMENT/PENSION

CIVIL SERVICE

OTHER (Specify):

WAGES

UNEMPLOYMENT
$

,

.

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

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if

Custodian of child, child, parent, or other)

CHILD

(4). GROSS MONTHLY INCOME

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

RETIREMENT/PENSION

CIVIL SERVICE

OTHER (Specify):

WAGES

UNEMPLOYMENT
$

,

.

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

VA FORM
XXX 20XX

21P-0969

SUPERSEDES VA FORM 21P-0969, NOV 2023

Page 4

SECTION III: RECURRING INCOME NOT ASSOCIATED WITH ACCOUNTS OR ASSETS (Continued)

(See instructions on Page 2)

3D.

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if

Custodian of child, child, parent, or other)

CHILD

(4). GROSS MONTHLY INCOME

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

RETIREMENT/PENSION

CIVIL SERVICE

OTHER (Specify):

WAGES

UNEMPLOYMENT
$

,

.

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

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if

Custodian of child, child, parent, or other)

CHILD

(4). GROSS MONTHLY INCOME

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

RETIREMENT/PENSION

CIVIL SERVICE

OTHER (Specify):

WAGES

UNEMPLOYMENT
$

,

.

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

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if

Custodian of child, child, parent, or other)

CHILD

(4). GROSS MONTHLY INCOME

(3). SPECIFY THE TYPE OF INCOME
SOCIAL SECURITY

RETIREMENT/PENSION

CIVIL SERVICE

OTHER (Specify):

WAGES

UNEMPLOYMENT
$

,

.

(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 2)

4A. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE ANY INCOME IN THE NEXT 12 MONTHS THAT IS RELATED TO FINANCIAL
ACCOUNTS?
NO (If "NO," skip to Section V)

YES
4B.

(4). SPECIFY THE TYPE OF INCOME EARNED

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

CHILD

INTEREST/DIVIDENDS
OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

parent, or other)

(5). GROSS MONTHLY INCOME
$

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

CHILD

parent, or other)

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

(5). GROSS MONTHLY INCOME

PARENT

OTHER (Specify):

CHILD

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

parent, or other)

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

,

,

.

INTEREST/DIVIDENDS
OTHER (Specify):
(5). GROSS MONTHLY INCOME
$

,

.

(6). VALUE OF ACCOUNT
$

VA FORM 21P-0969, XXX 20XX

.

(4). SPECIFY THE TYPE OF INCOME EARNED

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

,

(6). VALUE OF ACCOUNT
$

SPOUSE

.

INTEREST/DIVIDENDS

$

VETERAN

,

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

4D.

,

(4). SPECIFY THE TYPE OF INCOME EARNED

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

.

(6). VALUE OF ACCOUNT
$

4C.

,

,

,

.

Page 5

SECTION IV: INCOME AND NET WORTH ASSOCIATED WITH FINANCIAL ACCOUNTS (Continued)

(See instructions on Page 2)

4E.

(4). SPECIFY THE TYPE OF INCOME EARNED

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

CHILD

INTEREST/DIVIDENDS
OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

parent, or other)

(5). GROSS MONTHLY INCOME
$

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

,

(6). VALUE OF ACCOUNT
$

4F.

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

,

,

.

(4). SPECIFY THE TYPE OF INCOME EARNED

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

.

CHILD

INTEREST/DIVIDENDS
OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

parent, or other)

(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 2)

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

YES
5B.

(4). GROSS MONTHLY INCOME

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

CHILD
$

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

parent, or other)

,

.

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

,

,

.

(3). IDENTIFY THE TYPE OF ASSET AND SUBMIT THE REQUIRED FORM ASSOCIATED
FARM - VA FORM 21P-4165
5C.

BUSINESS - VA FORM 21P-4185

RENTAL PROPERTY - VA FORM 21P-4185
(4). GROSS MONTHLY INCOME

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

CHILD
$

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

parent, or other)

,

.

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

,

,

.

(3). IDENTIFY THE TYPE OF ASSET AND SUBMIT THE REQUIRED FORM ASSOCIATED
FARM - VA FORM 21P-4165
5D.

BUSINESS - VA FORM 21P-4185

RENTAL PROPERTY - VA FORM 21P-4185

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(4). GROSS MONTHLY INCOME
CHILD
$

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child,

parent, or other)

,

.

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

,

,

.

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

VA FORM 21P-0969, XXX 20XX

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 2)

6A. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE ANY INCOME AND NET WORTH ASSOCIATED WITH ROYALTIES AND OTHER
PROPERTIES?
NO (If "NO," skip to Section VII)

YES
6B.

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if

Custodian of child, child, parent, or other)

CHILD

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

EXTRACTION OF MINERALS/LUMBER

USE OF LAND

OTHER (Specify):
(4). GROSS MONTHLY INCOME
$

,

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

$

,

,

(6). CAN THE ASSET BE SOLD?
YES

.

NO

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

6C.

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if

Custodian of child, child, parent, or other)

CHILD

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

EXTRACTION OF MINERALS/LUMBER

USE OF LAND

OTHER (Specify):
(4). GROSS MONTHLY INCOME
$

,

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

$

,

,

(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 2)

7A. IN THE CURRENT YEAR AND/OR PRIOR 3 TAX YEARS, DID YOU OR YOUR DEPENDENTS SELL, CONVEY, TRADE, OR GIVE AWAY ANY ASSETS?
NO (If "NO," skip to Section VIII)

YES
7B.

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

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

(2). SPECIFY HOW THE ASSET WAS TRANSFERRED
SOLD

GAVE AWAY

CONVEYED

TRADED

CHILD

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

OTHER (Specify):
(3). WHAT ASSET WAS TRANSFERRED?

YES

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

(4). WHO RECEIVED THE ASSET?
(5). RELATIONSHIP TO NEW OWNER

NO

,

,

.

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

,

,

.

(11). WHAT WAS THE GAIN? (Capital gain, etc.)
(6). WAS THE SALE OF THE ASSET REPORTED TO THE IRS?
YES

NO

VA FORM 21P-0969, XXX 20XX

$

,

,

.

Page 7

SECTION VII: ASSET TRANSFERS (Continued)

(See instructions on Page 2)

7C.

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

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

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

CHILD

(2). SPECIFY HOW THE ASSET WAS TRANSFERRED
SOLD

GAVE AWAY

CONVEYED

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

TRADED

OTHER (Specify):

YES

(3). WHAT ASSET WAS TRANSFERRED?

NO

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

(4). WHO RECEIVED THE ASSET?

,

,

.

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

(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
7D.

NO

$

SPOUSE

CUSTODIAN OF CHILD

PARENT

OTHER (Specify):

GAVE AWAY

CONVEYED

.

CHILD

(2). SPECIFY HOW THE ASSET WAS TRANSFERRED
SOLD

,

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

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

,

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

TRADED

OTHER (Specify):

YES

NO

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

(3). WHAT ASSET WAS TRANSFERRED?

$
(4). WHO RECEIVED THE ASSET?

,

,

.

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

(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

NO

$

,

,

.

SECTION VIII: TRUSTS

(See instructions on Page 2)
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 on a separate VA Form 21P-0969 or provide the information on VA Form 21-4138 for each trust established.)
YES

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

8B. DATE TRUST ESTABLISHED

8C. SPECIFY MARKET VALUE OF ALL ASSETS WITHIN THE
TRUST AT TIME OF ESTABLISHEMENT

(MM/DD/YYYY)

8D. SPECIFY TYPE OF TRUST
ESTABLISHED
REVOCABLE

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

,

than one date, submit a VA Form 21-4138 with all dates
and amounts)

NO

NO

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

IRREVOCABLE

BURIAL TRUST

.

8F. WHEN DID YOU ADD FUNDS? (MM/DD/YYYY) (If more

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

,

8G. HOW MUCH DID YOU ADD?

$

,

.

8I. HOW MUCH DO YOU RECEIVE ANNUALLY?
$

,

.

8K. HOW MUCH IS BEING REIMBURSED MONTHLY?

or other service provider)
YES

NO

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

NO

VA FORM 21P-0969, XXX 20XX

,

$

.

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

NO

Page 8

SECTION IX: ANNUITIES

(See instructions on Page 2)
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 below information on VA Form 21-4138 for each annuity established.)
NO (If "NO," skip to Section X)

YES

9B. SPECIFY DATE ANNUITY WAS ESTABLISHED

(MM/DD/YYYY)

9C. SPECIFY MARKET VALUE OF ASSET AT TIME OF
ANNUITY PURCHASE
$

9E. WHEN DID YOU ADD FUNDS? (MM/DD/YYYY)

YES

.

,

NO

9G. IS THE ANNUITY REVOCABLE OR
IRREVOCABLE?

,

REVOCABLE

.

IRREVOCABLE

9I. IF YES IN 9H, PROVIDE ANNUAL AMOUNT RECEIVED (If NO, skip to 9J)

9H. DO YOU RECEIVE INCOME FROM THE
ANNUNITY?
NO

$

,

,

.

9K. IF YES IN 9J, PROVIDE THE SURRENDER VALUE (If NO, skip to Section X)

9J. CAN THE ANNUITY BE LIQUIDATED?
YES

,

9F. HOW MUCH DID YOU ADD?
$

YES

,

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

NO

$

,

,

.

SECTION X: ASSETS PREVIOUSLY NOT REPORTED

(See instructions on Page 2)

10A. DO YOU OR YOUR DEPENDENTS HAVE ASSETS NOT ALREADY REPORTED?
NO (If "NO," skip to Section XI)

YES
10B.

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

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

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

,

,

.

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

address, etc.)

10C.

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

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

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

,

,

.

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

address, etc.)

10D.

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

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

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

,

,

.

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

address, etc.)

10E.

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

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

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

,

,

.

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

address, etc.)

VA FORM 21P-0969, XXX 20XX

Page 9

SECTION XI: DISCONTINUED OR IRREGULAR INCOME

(See instructions on Page 2)

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

YES
11B.

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

(5). SPECIFY FREQUENCY OF INCOME RECEIVED
CHILD

IRREGULAR

ONE TIME PAYMENT

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child, parent, or other)

(6). DATE INCOME LAST PAID (MM/DD/YYYY)

(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.

RECURRING

$

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

,

.

(5). SPECIFY FREQUENCY OF INCOME RECEIVED
CHILD

RECURRING

IRREGULAR

ONE TIME PAYMENT

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child, parent, or other)

(6). DATE INCOME LAST PAID (MM/DD/YYYY)

(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 2)

12A. DID YOU OR YOUR DEPENDENTS WAIVE OR EXPECT TO WAIVE ANY RECEIPT OF INCOME IN THE NEXT 12 MONTHS?
NO (If "NO," skip to Section XIII Certification and Signature)

YES
12B.

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

CHILD

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

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child, parent, or other)

,

.

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

This income will not resume

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

(6). WAIVED GROSS MONTHLY INCOME
$
12C.

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

SPOUSE

PARENT

OTHER (Specify):

CUSTODIAN OF CHILD

CHILD

.

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

(2). SPECIFY NAME OF INCOME RECIPIENT (Only needed if Custodian of child, child, parent, or other)

,

,

.

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

This income will not resume

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

(6). WAIVED GROSS MONTHLY INCOME
$

,

.

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

VA FORM 21P-0969, XXX 20XX

13B. DATE SIGNED (MM/DD/YYYY)

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 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 SECOND WITNESS (If claimant signed above using an "X")

14E. PRINTED NAME OF SECOND WITNESS
FIRST:

MI:

LAST:

14F. ADDRESS OF SECOND 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, XXX 20XX

Page 11