Fillable NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE (U.S. Department of Veterans Affairs)

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NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE (U.S. Department of Veterans Affairs)

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FDC Criteria (Claim(s) for Veterans Pension Benefits
1. Submit your claim on a signed and completed VA Form 21P-527EZ, Application for Veterans Pension (attached).
2. Submit simultaneously with your claim:
All necessary income and asset information; AND
All, if any, relevant, private medical treatment records and an identification of any relevant
treatment records available at a Federal facility, such as a VA medical center.
Note: Read the Important note below and attach current medical evidence showing that you are permanently and totally
disabled, if necessary.
IMPORTANT: If you are a veteran who is claiming pension and you are age 65 or older, or determined to be disabled
by the Social Security Administration, you DO NOT have to submit medical evidence with your application unless you
are claiming special monthly pension. Special monthly pension is an increased amount paid to individuals who, due to
mental or physical disability, require the aid of another person to perform activities of daily living, are a patient in a
nursing home, have severe visual problems, or are substantially confined to his or her home.
Special Circumstances
Under the special circumstances shown below, you must also submit simultaneously with your claim:
If claiming veterans pension with special monthly pension, a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a nursing home)
a completed VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid
and Attendance;
If claiming a child in school between the ages of 18 and 23, a completed VA Form 21-674, Request for
Approval of School Attendance;
If claiming benefits for a seriously disabled child, all, if any, relevant, private medical treatment
records for the child's pertinent disabilities.
NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
VETERANS PENSION BENEFITS
VA FORM
OCT 2018
21P-527EZ
Page 1
.
3. Report for any VA medical examinations VA determines are necessary to decide your claim.
.
SUPERSEDES VA FORM 21P-527EZ, APR 2016,
WHICH WILL NOT BE USED.
.
.
.
(This notice is applicable to veterans claims for: Veterans Pension (a needs based benefit) • Special Monthly Pension • Benefits
Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for veterans pension.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and
there is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans pension, simply submit your
claim in accordance with the "FDC Criteria" shown below. If you are making a claim for veterans disability compensation or related
compensation benefits, use VA Form 21-526EZ, Application for Disability
Compensation and Related Compensation Benefits. If you are making a claim for survivor benefits, use
VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or Accrued Benefits.
VA forms are available at
www.va.gov/vaforms.
Department of Veterans Affairs
Pension Intake Center
PO Box 5365
Janesville, WI 53547-5365
WHERE TO SEND COMPLETED APPLICATION AND EVIDENCE
When you have completed this application, mail it to the Pension Intake Center listed below. Be sure to attach any
materials that support and explain your claim. Also, make a photocopy of your application and all supporting material you submit to
VA before mailing it.
MAIL TO
VA will:
• Retrieve relevant records from a Federal facility such as
a VA medical center, that you adequately identify and
authorize VA to obtain
• Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your
claim
• Make every reasonable effort to obtain relevant
records not held by a Federal facility that you adequately
identify and authorize VA to obtain. These may include
records from State or local governments and privately
held evidence and information you tell us about, such as
private doctor or hospital records or records from current
or former employers
The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!
Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are
entitled. If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your
claim, then VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard
Claim Process. See below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional
Expedited Process). If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim
Process.
WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant
evidence not in your possession.
Standard Claim Process
FDC Program (Optional Expedited Process)
You are strongly encouraged to:
• Send any information or evidence as soon as you can
You have up to one year from the date we receive the claim to
submit the information and evidence necessary to support your
claim. If we decide the claim before one year from the date we
receive the claim, you will still have the remainder of the one
year period to submit additional information or evidence
necessary to support the claim.
VA will:
• Retrieve relevant records from a Federal facility, such as
a VA medical center, that you adequately identify and
authorize VA to obtain
• Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your
claim
You must:
• If you know of evidence not in your possession and want
VA to try to get it for you, give VA enough information
about the evidence so that we can request it from the
person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure
we receive all requested records that are not in the possession
of a Federal department or agency.
VA FORM 21P-527EZ, OCT 2018
Page 2
You must:
• Submit your claim in accordance with the
"FDC Criteria" (see page 1)
HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
FDC Program (Optional Expedited Process)
Standard Claim Process
WHEN YOU SHOULD SEND WHAT WE NEED
You must:
• Send the information and evidence simultaneously with
your claim
If you submit additional information or evidence after you
submit your "fully developed" claim, then VA will remove the
claim from the FDC Program Expedited Process and process
it in the Standard Claim Process. If we decide your claim before
one year from the date we receive the claim, you will still have
the remainder of the one-year period to submit additional
information or evidence necessary to support the claim.
FDC Program (Optional Expedited Process)
Standard Claim Process
Veterans Pension with Special Monthly Pension
To support a claim for increased pension eligibility based on the need for aid and attendance, the evidence must show:
• You have corrected visual acuity of 5/200 or less in both eyes; OR
• You have concentric contraction of the visual field to 5 degrees or less; OR
• You are a patient in a nursing home due to mental or physical incapacity; OR
• You need the aid of another person to perform activities of daily living (ADLs), such as bathing or showering,
dressing, eating, toileting, and transferring (e.g. getting in and out of bed); OR
• You require regular supervision because you are unsafe if you are left alone due to a mental disorder, OR
• You are bedridden, in that your disability requires that you remain in bed apart from any prescribed course
of convalescence or treatment.
To support your claim for increased pension eligibility based on being housebound, the evidence must show:
• You have a single permanent disability evaluated as 100 percent disabling; AND due to such disability, you are
permanently and substantially confined to your immediate premises; OR
• You have a single permanent disability evaluated as 100 percent disabled, AND you have an additional disability or
disabilities rated 60 percent or higher.
Veterans Pension
To support a claim for veterans pension, the evidence must show:
1. You met certain minimum active service requirements during a period of war.
Generally, those requirements are:
• 90 days of service during a period of war; OR
• 90 days of consecutive service at least one day of which was during a period of war; OR
• 90 days of combined service during more than one period of war:
(Note: If your service began after September 7, 1980, additional length of service requirements may apply, typically
requiring two years of continuous service or completion of active-duty obligation)
• OR, any length of active service during a period of war with a discharge due to a service-connected disability
2. You are age 65 or older or are permanently and totally disabled. Your disability or disabilities do not have to be related
to your military service. You are considered permanently and totally disabled if medical evidence shows you are:
• A patient in a nursing home for long-term care or medical foster home; OR
• Receiving Social Security disability benefits; OR
• Unemployable due to a disability reasonably certain to continue throughout your lifetime; OR
• Suffering from a disability that is reasonably certain to continue throughout your lifetime that would make it
impossible for an average person to follow a substantially gainful occupation; OR
• Suffering from a disease or disorder that VA determines causes persons who have that disease or disorder
to be permanently and totally disabled
3. Your income and assets are within established limits. 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 (unless custody has been legally removed by a court and you do not contribute to your child's support
or the child's income is not reasonably available to you).
Assets means the fair market value of all property that an individual owns, including all real and personal property
(excluding the value of the primary residence including the residential lot area, not to exceed 2 acres) less the
amount of mortgages or other encumbrances specific to the mortgaged or encumbered property). Personal property
means the value of personal effects that are in excess of being suitable and consistent with a reasonable mode of life.
Child Incapable of self-support
Veterans Pension with Special Monthly Pension
VA FORM 21P-527EZ, OCT 2018
Page 3
WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
EVIDENCE TABLES
See the evidence table titled...
Veterans Pension
If you are claiming...
Veterans Pension (a needs-based benefit)
Special Monthly Pension
Benefits because your child is severely disabled
IMPORTANT
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)). Additional guidance on when VA recognized marriages is
available at http://www.va.gov/opa/marriage/.
For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/.
For more information on VA benefits, visit our web site at www.va.gov, 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 number is 711.
VA forms are available at
www.va.gov/vaforms.
Child Incapable of Self-Support
To support a claim for benefits based on a veteran's child being incapable of self-support, the evidence must show that the child,
before his or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.
Page 4
VA FORM 21P-527EZ, OCT 2018
If you wish to make a claim for veterans disability compensation and/or related compensation benefits, use VA Form 21-526EZ,
Application for Disability Compensation and Related Compensation Benefits. VA forms are available at www.va.gov/vaforms. If you
cannot access this form, write the words "Will claim compensation - send VA Form 21-526EZ" in Item 8 or at the top of the attached
application and VA will send you the form.
IMPORTANT
How VA Determines the Effective Date
If we grant your claim, the beginning date of your entitlement will generally be based on when we received your claim.
Special monthly pension may be assigned for disabilities that affect your ability to perform certain activities of daily living
or the ability to leave your home. Special monthly pension may be effective from the date the medical evidence first shows
entitlement.
EVIDENCE TABLES (Continued)
APPLICATION FOR VETERANS PENSION
9. LIST ANY VA MEDICAL CENTERS WHERE YOU RECEIVED TREATMENT FOR YOUR
CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES
A. DISABILITY(IES)
B. DATE(S) OF TREATMENT
3. DATE OF BIRTH (MM-DD-YYYY)
2. SOCIAL SECURITY NUMBER
OMB Control No. 2900-0002
Respondent Burden: 25 minutes
Expiration Date: 10/31/2021
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 12 before completing the form.
SECTION I: VETERAN'S PERSONAL INFORMATION (MUST COMPLETE)
6A. MAILING ADDRESS
4. HAVE YOU EVER FILED A CLAIM WITH VA?
(If "Yes," provide your file number
in Item 5)
CELL PHONEEVENING
6B. TELEPHONE NUMBERS
(Include Area Code)
7. PREFERRED E-MAIL ADDRESS (If applicable)
5. VA FILE NUMBER (If applicable)
1. VETERAN'S NAME (First, Middle Initial, Last)
8. WHAT DISABILITY(IES) PREVENTS YOU FROM WORKING?
A. NAME AND LOCATION OF VA MEDICAL CENTER
SUPERSEDES VA FORM 21P-527EZ, APR 2016,
WHICH WILL NOT BE USED.
Page 5
VA FORM
OCT 2018
21P-527EZ
B. DATE DISABILITY(IES) BEGAN
DAYTIME
YES
NO
ZIP Code/Postal CodeCountry
City
State/Province
Apt./Unit Number
No. &
Street
SECTION II: VETERAN'S SERVICE INFORMATION (MUST COMPLETE)
10A. DID YOU SERVE UNDER ANOTHER NAME? 10B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER
(If "No," skip to Item 11A)
(If "Yes," complete Item 10B)
YES
NO
SECTION III: VETERAN'S DISABILITY(IES) AND BACKGROUND (MUST COMPLETE)
11E. PLACE OF LAST SEPARATION
11A. I ENTERED ACTIVE SERVICE ON
(MM-DD-YYYY)
11C. RELEASE DATE FROM ACTIVE SERVICE (MM-DD-YYYY)
11B. BRANCH OF SERVICE
11D. SERVICE NUMBER
12B. DATES OF CONFINEMENT ON (MM-DD-YYYY)
12A. HAVE YOU EVER BEEN A PRISONER OF WAR?
(If "No," skip to Item 13A)
(If "Yes," complete Item 12B)
Page 6
VA FORM 21P-527EZ, OCT 2018
NOTE: You do not have to submit medical evidence or list disabilities if you are age 65 or older, unless you are housebound, or require the regular assistance of
another person.
SECTION II: VETERAN'S SERVICE INFORMATION (MUST COMPLETE) (CONTINUED)
From:
To:
YES
NO
13A. WHAT DISABILITY(IES) PREVENT YOU FROM WORKING?
13B. WHEN DID THE DISABILITY(IES) BEGIN? (MM-DD-YYYY)
14A. ARE YOU CLAIMING SPECIAL MONTHLY PENSION BECAUSE YOU NEED THE REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL
PROBLEMS, OR ARE GENERALLY CONFINED TO YOUR IMMEDIATE PREMISES?
(If "Yes," complete and attach with this application, VA Form 21-2680, Exam for Housebound Status or Permanent Need for Regular Aid
and Attendance. Please make sure every box is complete and signed by a Physician, Physician Assistant (PA), Certified Nurse Practitioner
(CNP), or Clinical Nurse Specialist (CNS.))
YES NO
14B. ARE YOU NOW OR HAVE YOU RECENTLY BEEN
HOSPITALIZED OR GIVEN OUTPATIENT OR HOME
CARE DUE TO THE DISABILITY(IES) LISTED IN
ITEM 13A?
NOYES
15B. NAME AND MAILING ADDRESS OF FACILITY OR DOCTOR
15A. DATE(S) OF RECENT HOSPITALIZATION OR CARE
(MM-DD-YYYY)
ARMY
AIR FORCE
NAVY
COAST GUARD
MARINE CORPS
NOTE: In the table below, tell us about all of your employment, including self-employment, for one year before you became disabled to the present.
16A. ARE YOU NOW EMPLOYED?
YES NO
16B. WHEN DID YOU LAST WORK? (MM-DD-YYYY)
NOYES
16C. WERE YOU SELF-EMPLOYED BEFORE BECOMING TOTALLY
DISABLED?
(If "Yes," complete Items 16D and 16E)
16D. WHAT KIND OF WORK DID YOU DO?
YES
NO
16E. ARE YOU STILL SELF-EMPLOYED?
YES NO
16F. WHAT KIND OF WORK DO YOU DO NOW?
(If "Yes," complete Item 16F)
NOYES
17A. ARE YOU NOW IN A NURSING HOME?
(If "Yes," complete Items 17B and 17C and submit a
statement from an official of the nursing home that
tells us that you are a patient in the nursing home
because of a physical or mental disability. The
statement should include the monthly charge you
are paying out-of-pocket for your care.)
17B. WHAT IS THE NAME AND COMPLETE MAILING ADDRESS OF THE FACILITY?
YES NO
17C. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME COSTS?
(If "No," complete Item 17D)
17D. HAVE YOU APPLIED FOR MEDICAID?
SECTION IV: MARITAL STATUS (MUST COMPLETE)
SECTION III: VETERAN'S DISABILITY(IES) AND BACKGROUND (MUST COMPLETE) (CONTINUED)
$
, .00
18E. HOW MANY DAYS WERE
LOST DUE TO DISABILITY?
18D. WHEN DID YOUR JOB END?
18C. WHEN DID YOUR JOB BEGIN?
18B. WHAT WAS YOUR JOB TITLE?
18A. WHAT WAS THE NAME AND
ADDRESS OF YOUR
EMPLOYER?
18F. WHAT WERE YOUR TOTAL
ANNUAL EARNINGS?
18F. WHAT WERE YOUR TOTAL
ANNUAL EARNINGS?
18A. WHAT WAS THE NAME AND
ADDRESS OF YOUR
EMPLOYER?
18B. WHAT WAS YOUR JOB TITLE?
18C. WHEN DID YOUR JOB BEGIN?
18D. WHEN DID YOUR JOB END?
18E. HOW MANY DAYS WERE
LOST DUE TO DISABILITY?
Page 7
VA FORM 21P-527EZ, OCT 2018
20D. HOW MARRIAGE ENDED (Death, Divorce,
Marriage Has Not Ended)
20C. TYPE OF MARRIAGE (Ceremonial,
Common-Law, Proxy, Tribal, or Other)
20B. TO WHOM MARRIED
(First, Middle, Last Name)
20E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED
(City and State or Country)
20A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE
(City and State or Country)
(Skip to Section VI if never married)
19A. WHAT IS YOUR MARITAL STATUS? (Check one)
TELL US ABOUT YOUR MARRIAGE/PREVIOUS MARRIAGES
19B. HOW MANY TIMES HAVE YOU BEEN MARRIED (Including current marriage)?
20A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE
(City and State or Country)
20E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED
(City and State or Country)
20B. TO WHOM MARRIED
(First, Middle, Last Name)
20C. TYPE OF MARRIAGE
(Ceremonial,
Common-Law, Proxy, Tribal, or Other)
20D. HOW MARRIAGE ENDED (Death, Divorce,
Marriage Has Not Ended)
WIDOWED
MARRIED DIVORCED
NEVER MARRIED
.00,
$
20F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 20C, PLEASE EXPLAIN:
TELL US ABOUT YOUR SPOUSE'S MARRIAGE/PREVIOUS MARRIAGES
21. HOW MANY TIMES HAS YOUR SPOUSE BEEN MARRIED (Including current marriage)?
SECTION V: CURRENT MARITAL INFORMATION (COMPLETE ONLY IF YOU ARE CURRENTLY MARRIED)
Note - Skip to Section VI if not currently married.
23B. WHAT IS YOUR SPOUSE'S SOCIAL
SECURITY NUMBER?
23D. WHAT IS YOUR SPOUSE'S VA FILE
NUMBER
(If any)?
23C. IS YOUR SPOUSE ALSO A VETERAN?
23A. WHAT IS YOUR SPOUSE'S DATE OF
BIRTH?
(MM-DD-YYYY)
NOYES
(If "Yes," complete Item 23D)
22D. HOW MARRIAGE ENDED (Death, Divorce,
Marriage Has Not Ended)
22C. TYPE OF MARRIAGE (Ceremonial,
Common-Law, Proxy, Tribal, or Other)
22B. TO WHOM MARRIED
(First, Middle, Last Name)
22E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED
(City and State or Country)
22A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE
(City and State or Country)
22A. DATE (MM-DD-YYYY) AND PLACE OF
MARRIAGE
(City and State or Country)
22E. DATE (MM-DD-YYYY) AND PLACE
MARRIAGE ENDED
(City and State or Country)
22B. TO WHOM MARRIED
(First, Middle, Last Name)
22C. TYPE OF MARRIAGE
(Ceremonial,
Common-Law, Proxy, Tribal, or Other)
22D. HOW MARRIAGE ENDED (Death, Divorce,
Marriage Has Not Ended)
22F. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22C, PLEASE EXPLAIN:
Page 8
VA FORM 21P-527EZ, OCT 2018
23F. WHAT IS YOUR SPOUSE'S ADDRESS? (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
(If "No," complete Items 23F, 23G and 23H)
(If "Yes," skip to Section VI)
YES NO
23E. DO YOU LIVE WITH YOUR SPOUSE?
ZIP Code/Postal CodeCountry
City
State/Province
Apt./Unit Number
No. &
Street
23H. HOW MUCH DO YOU CONTRIBUTE MONTHLY
TO YOUR SPOUSE'S SUPPORT?
23G. TELL US THE REASON YOU ARE NOT LIVING WITH YOUR SPOUSE
(i.e.; illness, work, etc.)
$
, .00
(Check all that apply)
(Check all that apply)
24C. SOCIAL SECURITY NUMBER
24A. NAME OF DEPENDENT CHILD
(First, Middle initial, Last)
24B. DATE AND PLACE OF BIRTH
(City and State or Country)
24I. CHILD MARRIED 24J. CHILD PREVIOUSLY MARRIED
24E. ADOPTED 24F. STEPCHILD24D. BIOLOGICAL
24H. SERIOUSLY DISABLED
24G. 18-23 YEARS OLD (in school)
.00,
$
No. &
Street
Apt./Unit Number
State/Province
City
Country ZIP Code/Postal Code
25A. NAME OF DEPENDENT CHILD
(First, middle initial, last)
25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)
25C. NAME OF PERSON THE CHILD LIVES WITH
(If applicable) (First, middle initial, last)
25D. MONTHLY AMOUNT YOU CONTRIBUTE TO THE CHILD'S SUPPORT
24G. 18-23 YEARS OLD (in school)
24H. SERIOUSLY DISABLED
24D. BIOLOGICAL 24F. STEPCHILD24E. ADOPTED
24J. CHILD PREVIOUSLY MARRIED 24I. CHILD MARRIED
24B. DATE AND PLACE OF BIRTH
(City and State or Country)
24A. NAME OF DEPENDENT CHILD
(First, Middle initial, Last)
24C. SOCIAL SECURITY NUMBER
(Check all that apply)
SECTION VI: DEPENDENT CHILDREN
(COMPLETE IF YOU HAVE DEPENDENT CHILDREN)
24C. SOCIAL SECURITY NUMBER
Note - Skip to Section VII if you have no dependent children.
24A. NAME OF DEPENDENT CHILD
(First, Middle initial, Last)
24B. DATE AND PLACE OF BIRTH
(City and State or Country)
24I. CHILD MARRIED 24J. CHILD PREVIOUSLY MARRIED
24E. ADOPTED 24F. STEPCHILD24D. BIOLOGICAL
24H. SERIOUSLY DISABLED
24G. 18-23 YEARS OLD (in school)
25D. MONTHLY AMOUNT YOU CONTRIBUTE TO THE CHILD'S SUPPORT
25C. NAME OF PERSON THE CHILD LIVES WITH
(If applicable) (First, middle initial, last)
25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)
25A. NAME OF DEPENDENT CHILD
(First, middle initial, last)
Note - In Items 25A through 25D, tell us about the children listed in Item 24A who do not live with you.
ZIP Code/Postal CodeCountry
City
State/Province
Apt./Unit Number
No. &
Street
$
, .00
VA FORM 21P-527EZ, OCT 2018
Page 9
VA FORM 21P-527EZ, OCT 2018
Page 10
B. GROSS MONTHLY AMOUNT
26. DO YOU OR YOUR DEPENDENTS RECEIVE SOCIAL SECURITY BENEFITS?
SECTION VII: QUESTIONS REGARDING INCOME AND ASSETS (If you need more space, attach a separate sheet.)
A. SOCIAL SECURITY RECIPIENT (First, middle initial, last)
YES NO
(If "No," skip to Item 27)
27. DO YOU OR YOUR DEPENDENTS OWN YOUR/YOUR FAMILY'S PRIMARY RESIDENCE?
(If "Yes," complete Items A and B)
YES NO
(If "No," skip to Item 29A) (If "Yes," complete Items 28A and 28B)
(If "Yes," also complete VA Form 21P-0969, Income and Asset Statement)
28A. WHAT IS THE SIZE OF THE LOT ON WHICH
THE PRIMARY RESIDENCE SITS?
Square feet
28B. COULD ANY PART OF THE LOT BE SOLD WITHOUT SELLING THE RESIDENCE?
YES
NO
29A. OTHER THAN SOCIAL SECURITY, DO YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME?
YES NO
29B. OTHER THAN SOCIAL SECURITY, DID YOU OR YOUR DEPENDENTS RECEIVE ANY INCOME LAST YEAR?
YES NO
29C. DO YOU OR YOUR DEPENDENTS HAVE MORE THAN $10,000 IN ASSETS?
(Note: Assets are all the money and property you or your dependents own. Assets do
not include your/your family's primary residence or personal effects such as appliances and vehicles you or your dependents need for transportation).
YES NO
29D. IN THE THREE CALENDAR YEARS BEFORE THIS YEAR, DID YOU OR YOUR DEPENDENTS TRANSFER ANY ASSETS?
(Examples of asset transfers include
giving them away, selling them, purchasing an annuity, or using them to establish a trust.)
YES NO
IMPORTANT: VA matches income information reported with Federal tax information. Report all income you and your dependents receive on the appropriate
sections of this form and VA Form 21P-0969, Income and Asset Statement, if appropriate.
SECTION VI: DEPENDENT CHILDREN (COMPLETE IF YOU HAVE DEPENDENT CHILDREN) (CONTINUED)
.00,
$
No. &
Street
Apt./Unit Number
State/Province
City
Country ZIP Code/Postal Code
25A. NAME OF DEPENDENT CHILD
(First, middle initial, last)
25B. CHILD'S COMPLETE ADDRESS (Number and street or rural route, city or P.O., city, State, ZIP Code and country)
25C. NAME OF PERSON THE CHILD LIVES WITH
(If applicable) (First, middle initial, last)
25D. MONTHLY AMOUNT YOU CONTRIBUTE TO THE CHILD'S SUPPORT
.00
.00
.00,
$
$
, .00
,
$
$
, .00
,
$
29E. DID YOU ANSWER "YES" TO ANY OF THE ITEMS IN 29A - 29D?
(If "Yes," you must also complete VA Form 21P-0969, Income and Asset Statement)
YES NO
SECTION VIII: INFORMATION ABOUT YOUR UNREIMBURSED MEDICAL EXPENSES
(If "No," skip to Section IX)
Family medical expenses and certain other expenses you actually paid may be deductible from your income. Show the amount of unreimbursed
medical expenses, including the Medicare deduction, you paid over the last year (or expect to pay and continue indefinitely) for yourself, dependents
you are under obligation to support, or relatives who are members of your household. Also, show unreimbursed last illness and burial expenses and
educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are unreimbursed amounts you paid for the last illness
and burial of a spouse or child at any time prior to the end of the year following the year of death. Educational or vocational rehabilitation expenses
are amounts you paid for courses of education including tuition, fees, and materials. Do not include any expenses for which you or your dependents
were/will be reimbursed. Please make sure to complete all 6 criteria below (if applicable). If more space is needed, complete and attach a separate
VA Form 21P-8416, Medical Expense Report.
IMPORTANT: If you are claiming expenses for in-home care or assisted living, adult day care, or similar facility, you must complete the
applicable worksheet(s) on pages 13 and 14.
30. ARE YOU OR YOUR DEPENDENTS CLAIMING UNREIMBURSED MEDICAL EXPENSES?
A. WHOSE MEDICAL, LEGAL, OR
OTHER EXPENSES WERE PAID?
B. PAID TO
(Name of Provider,
Insurance company,
Nursing home, etc.)
C. PURPOSE
(Medicare premiums,
Nursing Home,etc.)
D. DATE PAID
(MM-DD-YYYY)
E. HOURLY RATE/
HOURS
(In-home
Provider Only)
F. AMOUNT YOU
PAY
SECTION IX: DIRECT DEPOSIT INFORMATION (MUST COMPLETE)
31. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA.)
The Department of the the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit.
To enroll in direct deposit, provide the information requested below, and attach either a voided personal check or a deposit slip. If you do not have a
bank account, please visit https://www.benefits.va.gov/benefits/banking.asp. This website provides information about the Veterans Benefits Banking
Program (VBBP), and a link to banks and credit unions that may fit your needs. You may also call 1-800-827-1000. If you elect not to enroll, you must
contact representatives handling waiver requests for the Department of the Treasury at 1-888-224-2950. They will encourage your participation in EFT
and address any questions or concerns you may have.
Account No.:
33. ROUTING OR TRANSIT NUMBER (The first nine numbers located at the bottom
left of your check)
32. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank
where you want your direct deposit)
$
YES NO
SAVINGSCHECKING
$
$
.00
.00 $ .00
$ .00 $ .00
$ .00 $ .00
$ .00 $ .00
$ ,.00 $ .00
$ .00 $ .00
$ .00 $ .00
$ .00 $ .00
$ .00 $ .00
I CERTIFY THAT I DO NOT
HAVE AN ACCOUNT WITH A
FINANCIAL INSTITUTION OR
CERTIFIED PAYMENT AGENT
Page 11
VA FORM 21P-527EZ, OCT 2018
.00
SECTION X: CLAIM CERTIFICATION AND SIGNATURE (MUST COMPLETE)
I certify and authorize the release of information. I certify that the statements in this document are true and complete to the best of my knowledge. I
authorize any person or entity, including but not limited to any organization, service provider, employer, or government agency, to give the Department of
Veterans Affairs any information about me and I waive any privilege which makes the information confidential.
I certify I have received the notice attached to this application titled Notice to Veteran of Evidence Necessary to Substantiate a Claim for
Veterans Non-Service Connected Pension Benefits.
I certify I have enclosed all the information or evidence that will support my claim, to include an identification of relevant records available at a Federal
facility, such as a VA medical center; OR, I have no information or evidence to give VA to support my claim; OR, I have checked the box in Item 34,
indicating that I do not want my claim considered for rapid processing in the Fully Developed Claim (FDC) Program because I plan to submit further
evidence in support of my claim.
34. The FDC Program is designed to rapidly process compensation or pension claims received with the evidence necessary to decide the claim. VA will
automatically consider a claim submitted on this form for rapid processing under the FDC Program. Check the below box ONLY if you DO NOT
want your claim considered for rapid processing under the FDC Program because you plan to submit further evidence in support of your claim.
37B. PRINTED NAME AND ADDRESS OF WITNESS
PRIVACY ACT NOTICE: The form will be used to determine allowance to pension benefits (38 U.S.C. 5101). The responses you submit are considered confidential
(38 U.S.C. 5701). VA may disclose the information that you provide, including Social Security numbers, outside VA if the disclosure is authorized under the Privacy Act,
including the routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment
Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits under the law.
Information submitted is subject to verification through computer matching programs with other agencies. VA may make a "routine use" disclosure for: 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. Your
obligation to respond is required in order to obtain or retain benefits. Information that you furnish may be utilized in computer matching programs with other Federal or
State agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your
participation in any benefit program administered by the Department of Veterans Affairs. Social Security information: You are required to provide the Social Security
number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the Privacy Act, and, specifically may disclose them for
purposes stated above.
SECTION XI: WITNESSES TO SIGNATURE (MUST COMPLETE ONLY IF VETERAN SIGNED ITEM 35A WITH AN "X")
36A. SIGNATURE OF WITNESS (If veteran signed above using an "X") 37A. SIGNATURE OF WITNESS (If veteran signed above using an "X")
35B. DATE SIGNED
36B. PRINTED NAME AND ADDRESS OF WITNESS
35A. VETERAN'S SIGNATURE (REQUIRED)
RESPONDENT BURDEN: We need this information to determine your eligibility for pension. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 25 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.
I DO NOT want my claim considered for paid processing under the FDC Program because I plan to submit further evidence in support of my claim.
Name:
Address:
Name:
Address:
VA FORM 21P-527EZ, OCT 2018
Page 12
STEP 8. Facility Certification: Please submit a current statement showing the fees the claimant pays to your facility and a breakdown of the care
received.
I CERTIFY that the information stated within this WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY is accurate
and reflects the current environment pertaining to
and his or her care at this facility
at
WORKSHEET FOR AN ASSISTED LIVING, ADULT DAY CARE, OR SIMILAR FACILITY
NOTE: Only complete this worksheet if you are claiming expenses for an assisted living facility, adult day care or similar facility.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular -
• assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder.
INSTRUCTIONS: Use this worksheet if you are claiming a disabled person's care in an assisted living facility, adult day care, or similar facility as unreimbursed
medical expenses. Follow the steps below to determine whether VA may deduct all or some of your out-of-pocket payments to the facility.
STEP 1. Are the expenses you wish to claim due to the disabled person's treatment in a hospital, inpatient treatment center, nursing home, or VA
approved medical foster home?
(If "NO," payments to the facility do not qualify as medical expenses. You are finished completing this worksheet)
(If "YES," all payments to the facility qualify as medical expenses in Items 30A - 30F. You are finished completing this worksheet)
STEP 2. Do all of the following apply to the facility?
• The facility is licensed (if the State or Country requires it)
• The facility's staff (or the facility's contracted staff) provides the disabled person with
health care or custodial care or both.
• If the facility is residential, it is staffed 24 hours per day with caregivers
STEP 3. Are you (the veteran) the disabled person?
(If "NO," skip to Step 6)
STEP 4. Did you claim special monthly pension on Page 5, Item 14A of the attached form?
(If "NO," payments to this facility for meals and lodging do not qualify as medical expenses. Only claim amounts you pay the facility for health care
services or assistance with ADLs provided by a health care provider in Items 30A - 30F. Skip to Step 8)
STEP 5. If you answered "YES" in Step 2, you stated that the facility provides you with health care and/or custodial care. Is this the primary reason you
live in the facility (or attend day care in the facility)?
(If "YES," all payments to this facility may qualify as medical expenses if VA rates you as eligible for special monthly pension. Please report
separately in Items 30A - 30F applicable amounts you pay the facility for (1) lodging and meals, (2) health care services or assistance with
ADLs provided by a health care provider, and (3) custodial care. Skip to Step 8)
STEP 6. Does the disabled person require the health care services or custodial care that the facility provides to him or her because of the disabled
person's mental or physical disability?
(If "YES," you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care services
or custodial care that the facility provides to him or her because of mental or physical disability, and (2) describes the mental or physical disability)
(If "NO," claim payments you pay this facility for health care services or assistance with ADLs provided by a health care provider in Items 30A
- 30F. Skip to Step 8)
STEP 7. If you answered "YES" in Step 2, you stated that the facility provides the disabled person with health care and/or custodial care. Is this the
primary reason the disabled person lives in the facility (or attends day care in the facility)?
(If "NO," only claim payments you pay the facility for assistance with health care and/or assistance with custodial care as medical expenses in
Items 30A - 30F. Payment to this facility for meals and lodging do not qualify)
(If "NO," continue to Step 2)
(If "YES," claim all payments to this facility (to include meals and lodging) as medical expenses in Items 30A - 30F)
(Name of Person Staying at Facility)
(Name of Facility)
(Title of Person Certifying for the Facility) (Date Certified)
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
(Address of Facility (Line 1))
(Address of Facility (Line 2))
(Signature of Person Certifying for the Facility)
(Name of Person Certifying for the Facility)
VA FORM 21P-527EZ, OCT 2018
Page 13
STEP 7. In-Home Attendant Certification: Please submit a current breakdown of the time the attendant spends assisting the veteran or disabled
person with health care services, ADLs and IADLs.
STEP 4. Does the disabled person require the health care services or custodial care that the in-home attendant provides to him or her because of the
disabled person's mental or physical disability?
STEP 2. Did you claim special monthly pension on Page 5, Item 14A of the attached form?
WORKSHEET FOR IN-HOME ATTENDANT EXPENSES
NOTE: Only complete this worksheet if you are claiming expenses for in-home care.
IMPORTANT: VA recognizes the following five activities as Activities of Daily Living (ADLs) for medical expense purposes:
(1) Eating
(2) Bathing/Showering
(3) Dressing
(4) Transferring (for example, from bed to chair)
(5) Using the toilet
Custodial Care is regular -
• assistance with two or more ADLs, or
• supervision because a person with a mental disorder is unsafe if left alone due to the mental disorder
IMPORTANT: The following activities are examples of Instrumental Activities of Daily Living (IADLs) for VA purposes. VA generally does not recognize assistance
with these activities as medical expenses: (1) Shopping; (2) Food Preparation; (3) Housekeeping; (4) Laundering; (5) Handling medications; (6) Using the
telephone; (7) Transportation (except for medical purposes such as transportation to a doctor's appointment).
INSTRUCTIONS: Use this worksheet if you are claiming payments to a disabled person's in-home attendant as an unreimbursed medical expense.
Follow the steps below to determine whether or not:
• the attendant must be a health care provider for VA purposes and
• VA may deduct payment for assistance with IADLs as well as assistance with ADLs and custodial care
STEP 1. Are you (the veteran) the disabled person?
(If "NO," skip to Step 4)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in Items 30A -
30F applicable amounts you pay an in-home attendant for (1) health care services or assistance with ADLs provided by a health care provider, and
(2) custodial care. Skip to Step 6)
STEP 3. Is the primary responsibility of the in-home attendant to provide you with health care or custodial care?
(If "YES," payments to this in-home attendant may qualify as medical expenses in Items 30A - 30F if VA rates you as eligible for special monthly
pension. Please report separately in Item 30A - 30F amounts you pay an in-home attendant for (1) health-care services or assistance with ADLs
provided by a health care provider, (2) assistance with IADLs, and (3) custodial care. Skip to Step 6.)
(If "YES," you must submit a statement from a physician or physician assistant that (1) the disabled person requires the health care services or
custodial care that the in-home attendant provides to him or her because of mental or physical disability, and (2) describes the mental or physical
disability)
(If "NO," payments to this in-home attendant for assistance with IADLs do not qualify as medical expenses. Please report separately in Items 30A -
30F applicable amounts you pay an in-home attendant for: (1) health care services or assistance with ADLs provided by a health care provider and
(2) custodial care. Skip to Step 6.)
(If "NO," the attendant must be a health care provider. Only report payments to the in-home attendant for health care services or assistance
with ADLs provided by the health care provider as medical expenses in Items 30A - 30F. Payments for assistance with IADLs do not qualify as
medical expenses. Skip to Step 6.)
STEP 5. Is the primary responsibility of the in-home attendant to provide the disabled person with health care or custodial care?
(If "YES," payments to the in-home attendant qualify as medical expenses (even assistance with IADLs) and can be reported in Items 30A - 30F.)
I CERTIFY that the information stated within this WORKSHEET FOR IN-HOME ATTENDANT EXPENSES is accurate and reflects the current
environment pertaining to
and his or her care from
(Name of Person Requiring Care)
(Name of Attendant)
(If "NO," report payments to this in-home attendant for health care and/or custodial care as medical expenses in Items 30A - 30F. Payment for
assistance with IADLs do not qualify as a medical expense)
STEP 6. Check all activities below with which the attendant assists the veteran or disabled person with:
ADLs:
IADLs:
YES NO
YES NO
YES NO
YES NO
YES NO
SHOPPING
EATING
BATHING/SHOWERING USING THE TOILETTRANSFERRING
FOOD PREPARATION MANAGING FINANCESLAUNDERINGHOUSEKEEPING
HANDLING MEDICATIONS
TRANSPORTATION FOR NON-MEDICAL PURPOSESUSING THE TELEPHONE
DRESSING
(Title of Certifying Official) (Date Certified)
(Signature of Certifying Official)
(Name of Certifying Official)
VA FORM 21P-527EZ, OCT 2018
Page 14
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