SECTION IV - HOSPITAL AND MEDICAL EXPENSES
8. DO YOU EXPECT TO MAKE PROVISIONS FOR YOUR CHILDREN'S EDUCATIONAL NEEDS, INCLUDING ADVANCED TECHNICAL OR COLLEGE EDUCATION?
7B. ESTIMATED COST PER YEAR
$
7C. EXPLANATION
SECTION V - EDUCATIONAL EXPENSES
9A. NAME OF DECEASED PERSON (First-middle-last)
SECTION VI - EXPENSES OF LAST ILLNESS AND BURIAL OF VETERAN, SPOUSE, OR CHILD
AND JUST DEBTS OF DECEASED VETERAN OR PARENT'S SPOUSE
7A. DO YOU HAVE OR EXPECT TO HAVE ANY LARGE OR UNUSUAL HOSPITAL OR MEDICAL EXPENSES FOR YOURSELF
AND OTHERS YOU SUPPORT AND LIVE WITH?
Privacy Act Information: 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, 58VA21/22, Compensation, Pension, Education and Rehabilitation 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 entitlement to benefits. 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. 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.
9C. DATE OF DEATH9B. RELATIONSHIP TO YOU
EXPENDITURES FOR ABOVE-NAMED PERSON
NOTE - Furnish information concerning unreimbursed expense as follows:
A CHILD - For veteran's last illness, burial and just debts.
A SPOUSE - For the last illness and burial of veteran's child.
A WIDOW(ER) - For veteran's last illness, (paid before or after
the veteran's death), burial and just debts and for the last illness
and burial of veteran's child.
A PARENT - For his/her spouse's or veteran's last illness and burial
and for his/her spouse's just debts.
A VETERAN - For his/her spouse's or child's last illness and burial.
10A. NAME AND ADDRESS OF
PERSON TO WHOM PAID
10C. TOTAL AMOUNT
OF EXPENSES OR DEBT
10B. NATURE OF
EXPENSES OR DEBT
10D. AMOUNT
PAID BY YOU
10E. DATE
PAID
$
SECTION VII - COMMERCIAL LIFE INSURANCE PAYMENTS
11A.
11B.
AMOUNT
NOTE: Under Public Law 108-454, VA may not count as income the lump sum proceeds of a life insurance policy on a
veteran who dies after December 9, 2004. Proceeds from all other insurance payments may be countable.
EXPECTED OR ACTUAL DATE OF RECEIPT (If paid by installments, explain payment schedule in
Item 12, Remarks)
TOTAL RECEIVED OR EXPECTED BY CLAIMANT
12. REMARKS
PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission or any statement or evidence of a material fact,
knowing it to be false.
I CERTIFY THAT the foregoing statement(s) are true and correct to the best of my knowledge and belief.
13. SIGNATURE OF CLAIMANT (Do not print, sign in ink)
14. DATE
15. TELEPHONE NUMBER(S) (Include Area Code)
A. DAYTIME B. EVENING
Respondent Burden: We need this information to determine entitlement to pension or parent's dependency and indemnity compensation (38 U.S.C. 1503 and 1315). Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 15 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.
$
$
$
$
$
$
$
$
YES NO
YES
CHILD PARENTSPOUSE
NO
VA FORM 21P-8049, SEP 2016
11C.
NAME OF THE DECEASED FOR WHOM PAYMENT IS RECEIVED.
