7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
SOCIAL SECURITY
$
$
SOURCE SURVIVING SPOUSE
10A. SIGNATURE OF PAYEE (
Read paragraph 9 of the EVR Instructions before signing)
7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR Instructions)
SOURCE
SURVIVING SPOUSE
If no income or net worth 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
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.".
GROSS WAGES FROM
ALL EMPLOYMENT
Normally, medical expenses are reported at the end of the year. 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, to report your medical expenses. 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 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. FAMILY 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
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.
10B. DATE SIGNED
SOURCE
$
10C. TELEPHONE NUMBERS (Include Area Code)
DAYTIME EVENING
THRU:
FROM:
THRU:
$
9. SURVIVING SPOUSE'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 CHILDREN'S
EXPENSES.
NO
YES
VA FORM 21-0518-1, FEB 2012
