VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
OMB Approved No. 2900-0666
Respondent Burden: 30 minutes
Expiration Date: 7/31/2024
INFORMATION REGARDING APPORTIONMENT OF BENEFICIARY'S AWARD
C/CSS-
$
INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. All or part of a
veteran's disability award may be apportioned (paid) to the veteran's spouse, child, or dependent parent. A surviving spouse's
award may also be apportioned for the veteran's child or children. 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)). For additional space, or to describe any financial hardship (not otherwise reflected on this form) you are
experiencing or will experience based on the outcome of this claim, use Part III - Remarks. For more information, contact us at
https://iris.custhelp.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD),
the Federal relay number is 711. VA forms are available at www.va.gov/vaforms. After completing the form, mail to:
Department of Veterans Affairs, Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.
5B. HOW OFTEN ARE THE CONTRIBUTIONS MADE?
4A. WHO ARE YOU REQUESTING AN APPORTIONMENT FOR? (List first, middle initial, and last names)
VA FORM
JUL 2021
21-0788
1. VETERAN'S NAME (First, Middle Initial, Last)
3B. MAILING ADDRESS
(Number and street or rural route, city or
P.O., State and ZIP Code)
3C. TELEPHONE NUMBER (Include Area Code)
5A. HOW MUCH IS THE VETERAN OR VETERAN'S SURVIVING SPOUSE CONTRIBUTING TO THE PERSON(S)
FOR WHOM AN APPORTIONMENT IS BEING CLAIMED?
7. HAS THE VETERAN'S CHILD(REN) BEEN
LEGALLY ADOPTED BY ANOTHER PERSON?
PART I - INCOME AND NET WORTH
4B. WHAT IS HIS/HER RELATIONSHIP TO THE
VETERAN?
6. IF THE SPOUSE IS CLAIMING AN APPORTIONMENT, IS HE/SHE LIVING WITH ANOTHER PERSON AND
HOLDING HIMSELF/HERSELF OUT OPENLY TO THE PUBLIC AS THE SPOUSE OF THE OTHER PERSON?
Report all income and net worth. Report the gross amounts before you take out deductions for taxes, insurance, etc. If you do not receive income or net worth from a particular source, write
"0" or "none" in the space provided. Do not leave the space blank. Note: If you are the veteran or surviving spouse, report only your income and net worth. If you are the claimant or are filing
on behalf of the claimant(s), report all income and net worth for all persons for whom an apportionment is being claimed. If you are claiming an apportionment as the custodian of the veteran's
child or children, report your income and net worth and the income and net worth of the child(ren).
(If "Yes," provide an explanation in Part III - Remaks)
:
SOURCE
VETERAN OR
SURVIVING SPOUSE
CUSTODIAN
2F. ALL OTHER PROPERTY AND
ASSETS
2C. IRAS, KEOGH PLANS, ETC.
2B. INTEREST-BEARING BANK
ACCOUNTS
2D. STOCKS, BONDS, MUTUAL
FUNDS, ETC.
2A. CASH/NON-INTEREST-BEARING
BANK ACCOUNTS
NET WORTH
PERSON APPORTIONMENT
IS CLAIMED FOR
2E. REAL PROPERTY
(Not your home)
$
PERSON APPORTIONMENT
IS CLAIMED FOR
$ $ $
MONTHLY INCOME
PERSON APPORTIONMENT
IS CLAIMED FOR
$
SOURCE
VETERAN OR
SURVIVING SPOUSE
CUSTODIAN
1F. OTHER INCOME
(Show source)
1C. RETIREMENT OR ANNUITIES
1B. SOCIAL SECURITY
1D. SUPPLEMENTAL SECURITY
INCOME (SSI) / PUBLIC ASSISTANCE
1A. GROSS WAGES FROM ALL
EMPLOYMENT
1E. OTHER INCOME
(Show source)
PERSON APPORTIONMENT
IS CLAIMED FOR
$ $ $
SUPERSEDES VA FORM 21-0788, MAR 2018.
2. VA FILE NUMBER (If known)
Evening
3A. PERSON COMPLETING THIS FORM (First, Middle Initial, Last) (If other than veteran)
Daytime
3D. E-MAIL ADDRESS
(If applicable)
YES NO YES NO
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