11C. TELEPHONE NUMBERS (Include Area Code)
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a
material fact, knowing it is false, or fraudulent acceptance of any payment to which you are not entitled.
7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
SOCIAL SECURITY
$ $ $$
SPOUSESOURCE VETERAN
11A. SIGNATURE OF VETERAN
(Read paragraph 9 of the EVR Instructions before signing)
7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
SOURCE VETERAN SPOUSE
GROSS MONTHLY AMOUNTS (If no income was received from a particular source, write "0" or "none." VA WILL INTERPRET A BLANK SPACE AS "NONE" or "0.")
MILITARY RETIREMENT
$
U. S. CIVIL SERVICE
U. S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
OTHER (Show Source)
OTHER (Show Source)
NOTE: Report annual income for the dates indicated. If no dates are shown above the columns that follow, then report last calendar year (January
through December) income in the left-hand column and current calendar year income in the right-hand column.
If no income was received from a particular source, write "0" or "none". VA WILL INTERPRET A BLANK SPACE AS "NONE" or "0."
SPOUSE
GROSS WAGES FROM
ALL EMPLOYMENT
If you are using this form as your annual Eligibility Verification Report and Paragraph 6 of the EVR Instructions indicates that you should report medical
expenses, use VA Form 21-8416, Medical Expense Report. If you are using this form as a supplement to a pending claim, you do not need to report
medical expenses. If entitlement is established, you will have an opportunity to report your medical expenses at the end of the year.
TOTAL INTEREST AND
DIVIDENDS
ALL OTHER
(Show Source)
ALL OTHER
(Show Source)
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE PAST 12 MONTHS? (Answer "NO" if there were no income changes or if the
only change was a Social Security/VA cost-of-living adjustment. Answer "YES" if there were any other income changes or if you received
any NEW source of income or any ONE-TIME income)
FROM:
8. MEDICAL EXPENSES
(Read Paragraph 6 of the EVR Instructions)
(If "YES," complete Items 7D through 7F. If "NO," go to Item 7G.)
7D. WHAT INCOME CHANGED? (Show what
income changed, for example, wages, city
pension, etc.)
7E. WHEN DID THE INCOME CHANGE? (Show
the dates you received any new income or the
date income changed)
7F. HOW DID INCOME CHANGE? (Explain what
happened; for example, quit work, got raise,
received inheritance)
7G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
CASH/NON- INTEREST-BEARING BANK ACCOUNTS
INTEREST-BEARING BANK ACCOUNTS
IRA'S, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY
(Not your home)
ALL OTHER PROPERTY
11B. DATE SIGNED
SOURCE
VETERAN
$
$
DAYTIME EVENING
$
THRU:
FROM:
THRU:
FROM:
THRU:
FROM:
THRU:
$
9. VETERAN'S EDUCATIONAL AND VOCATIONAL REHABILITATION EXPENSES (Read Paragraph 7 of the EVR
Instructions)
Show amounts paid by you during the past 12 months. DO NOT REPORT DEPENDENTS' EXPENSES.
10. FAMILY MAINTENANCE
(Hardship) EXPENSES FOR THE NEXT 12 MONTHS (Read Paragraph 8 of the EVR
Instructions). Complete ONLY IF VA is currently excluding children's income on the grounds of hardship. Show total
family expenses expected for the next 12 months.
$
CHILD:
$
CHILD:
$
OTHER (Show Source)
$ $
CHILD:
FROM:
THRU:
FROM:
THRU:
NOYES
VA FORM 21-0517-1, FEB 2012
