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
Page 1
PART II - MONTHLY LIVING EXPENSES
Show your monthly living expenses, including any monthly installment payments. If you do not have expenses 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 expenses. If you are the claimant or are filing on behalf of the claimant(s),
report expenses 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 expenses and the expenses of the child(ren).
1D. TELEPHONE
1E. CLOTHING
1C. UTILITIES Water, gas, electricity)
1F. MEDICAL EXPENSES
1G. SCHOOL EXPENSES
1H. OTHER EXPENSES
(Show source)
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.
PERSON APPORTIONMENT
IS CLAIMED FOR
$
SOURCE
VETERAN OR
SURVIVING SPOUSE
CUSTODIAN
1B. FOOD
1A. RENT OR HOUSE PAYMENT
1I. OTHER EXPENSES
(Show source)
PERSON APPORTIONMENT
IS CLAIMED FOR
$ $ $
The 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, 58VA 21/22/28, Compensation,
Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register.Your obligation to respond is required to obtain or
retain benefits. The requested information is considered relevant and necessary to determine maximum benefits under the law. 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.
We need this information to determine whether an apportionment of VA disability or death benefits may be made (38 U.S.C. 5307). Title
38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information,
and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a
collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
PART III - REMARKS
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
9. SIGNATURE OF VETERAN OR CLAIMANT (Required)
10. DATE SIGNED
(MM/DD/YYYY)
VA FORM 21-0788, JUL 2021
Page 2
RESPONDENT BURDEN -
PRIVACY ACT INFORMATION -
8. REMARKS
PART IV - CERTIFICATION AND SIGNATURE
click to sign
signature
click to edit