Fillable Updated AA Packet 2019

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Updated AA Packet 2019

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VA
AID
&
ATTENDANCE/HOUSEBOUND
PENSION
APPLICATION
PACKET
Department of Veteran Services
294 Main Street ● Greenfield, MA 01301
Phone 413-772-1571 ● Fax 413-772-1401
www.greenfield-ma.gov
UPPER PIONEER VALLEY VETERANS’ SERVICES DISTRICT
Veteran Resource and Referral Center located in Greenfield, satellite locations throughout the district
Timothy Niejadlik, Director
Laura Thorne, Assistant
Christopher Demars, VSO
Brian Brooks, VSO
Dear Veteran:
You or a family member has made an inquiry about assistance in paying for costs associated
with visiting nurses, home health aides, assisted living or long-term care.
Attached is a handout describing a VA benefit available to wartime veterans and their
spouses/widows and known as Aid and Attendance/Housebound. Please review the
information to determine if it applies to you, your spouse or both. If it appears to apply, please
complete the two forms (VA Forms 21-2680 and 21P-8416) which are available at the links
provided and then complete the final application form (VA Form 21P-527EZ for veteran) or
(VA Form 21-534EZ for widow/widower of veteran), a VA 21-0779 if in nursing home, the
VA 21-0845(release form) Following are instructions for the two main forms.
VA Form 21-2680 http://www.vba.va.gov/pubs/forms/VBA-21-2680-ARE.pdf
This form must be filled out by a medical doctor and describe the specific tasks or daily
routines with which you require assistance. If you do not require assistance with any of these
tasks, the VA will not approve the benefit.
VA Form 21P-8416 http://www.vba.va.gov/pubs/forms/VBA-21P-8416-ARE.pdf
This form is a summary of all out of pocket medical expenses incurred by you or your spouse
during the previous 12 calendar months. These costs may include medical premiums such as
your Medicare B premium which is deducted from your Social Security, your Medigap
premium, Part D premium, all co-pays for treatments or prescriptions.
If you are incurring actual costs for home health care or for assisted living, you may report
these costs as well. You may not include expected future costs if they are not currently being
incurred.
Enter one provider per line. For example if you or your spouse incur co-pays from CVS every
month, enter a single line for the full yearly amount and enter “annual” in column C.
After you have reviewed the description of the benefits, determined that the benefit is
applicable and completed both forms, contact our office and we will assist you in completing
the rest of the application process.
Sincerely yours,
Timothy Niejadlik
Director and Agent
Member Towns
Ashfield
Bernardston
Buckland
Charlemont
Colrain
Conway
Deerfield
Erving
Gill
Greenfield
Hawley
Heath
Leverett
Leyden
Monroe
Montague
New Salem
Northfield
Plainfield
Rowe
Shelburne
Shutesbury
Sunderland
Warwick
Wendell
Whately
Member Towns
Ashfield
Bernardston
Buckland
Charlemont
Colrain
Conway
Deerfield
Erving
Gill
Greenfield
Hawley
Heath
Leverett
Leyden
Monroe
Montague
New Salem
Northfield
Plainfield
Rowe
Shelburne
Shutesbury
Sunderland
Warwick
Wendell
Whately
Department
of
Veteran
Services
294
Main
Street
•
Greenfield,
MA
01301
Phone
413-772-1571
•
Fax
413-772-1401
www.ureenfield-ma.gov
Timothy
Niejadlik,
Director
Laura
Thorne,
Assistant
Brian
Brooks,
1~SO
Christopher
Dernars,
VSO
UPPER
PIONEER
VALLEY
VETERANS’
SERVICES
DISTRICT
l4jtera,,
Resource
alit!
Referra!
center
!ocated
in
Green/kid,
sate/lire
locations
throughout
the
district
Pension
with
Aid
and
Attendance/Housebound
General
Description
of
the
Benefit
(Applies
to
either
Veteran
or
Widow)
Wartime
veterans
and
spouses/widows who
are
seriously
disabled
may
quali~’
for
Aid
and
Attendance
or
Housebound
benefits. This
benefit
may
also
be
applied
for
by
those
with
service-com~ected
compensation
provided
that
the
compensable
injury
is
causing
the
need
for
the
Aid
and
Attendance.
Widow’s
who
are
eligible
for
VA Widow’s
pension
may
also
file
for
Aid
and
Attendance
if
they
meet
the
criteria.
Initial Screening
Net
worth:
Gross
income plus
gross
assets
(excluding
primary
home)
may
not
exceed
$80,000.
If
slightly
higher,
the
VA
recommends
filing
and
allowing
them
to
decide
on
a
case-by-case
basis.
Countable Income:
Income
received
by
the
veteran
and
his
or
her
spouse,
from
most
sources.
Includes
earnings,
disability
and
retirement
payments, interest
and
dividends,
and
net
income
from farming
or
business.
VA
will
not
count
881
but
it
should
be
reported.
Assets:
Includes
bank
accounts,
stocks,
bonds,
mutual
ffinds
and
any
property
other
than
the
primary
veteran’s
residence.
Calculation
of
Benefit
The
VA
uses
a
benchmark
of
approximately
$11
76/month
(widow),
$1402
(spouse
of
living
vet),
$183
0/month
(single
veteran)
or
$2169/month (couple),
subtracts
all incomes
for
both
parties
and
pays
the
difference
as
a
benefit.
Medical
premiums
and
expenses
will
be
counted
by
the
VA
to
reduce
gross
incomes.
Medical
expenses
include
Medicare
B
for
both
parties,
supplemental
premiums,
all
co-pays,
dental
expenses,
Visiting
nurses
and
assisted
living
costs.
The
Ton’n
of
Greenfleld
is
an
Affirm
ati,’e
Action/Equal
Opportunity
Employer,
a
designated
Greet:
community
and
a
recipient
of
the
“Leading
by
Example”A
ward
Page 2
The
VA
will
total
all
countable income
and
subtract
allowed
medical
deductions.
The
remaining
countable
income
after
deductions
is
subtracted
from
the
appropriate
benchmark
limit.
The
resulting
benefit
is
paid
directly
to
the
veteran.
Supporting
Documentation
Physician’s
Report
—
Must
report
in
detail
exactly
what
services
must
be
performed
by
nursing
assistants
including
the
ability
to
dress
and
undress, to feed
oneself;
to
attend
to
sanitary
needs,
and
to keep
oneself
ordinarily
clean
and
presentable.
In
addition, it
is
necessary
to
determine
whether
the
claimant
is
confined
to
the
home
or
immediate
premises.
Whether
the
claim
is
for
Aid
and
Attendance or
Housebound,
the
report
should
indicate
how well
the
individual
gets
around,
where
the
individual
goes, and
what
he
or
she
is
able
to
do
during
a
typical
day.
If
in Nursing
home
-
statement
from
nursing
home
with
date
of
admission
and
status.
Considerations
A
veteran
or
widow
may
be
eligible for
A&A
when applicant:
Requires
aid
of
another
person
to
perform
personal
everyday
functions
(bathing,
feeding,
dressing,
wants
of
nature,
adjusting
prosthetic
devices,
or
protection
from
the
hazards
of
daily
environment,
-
or
Is
bedridden,
in
that
disabilities
require
remaining
in
bed
apart
from
any course
of
convalescence
or
treatment,
-or
Is
a
patient in
a
nursing
home
due to
mental
or physical
incapacity,
-or
Is
blind,
or
nearly
blind
(corrected
acuity
of
5/200
or
less,
in
both
eyes,
or visual
field
of
5
degrees
or
less.
A
veteran
or
widow
may
be
eligible
for
Housebound
benefits when
the veteran
has:
A
single
permanent
disability
evaluated
as
100-percent
disabling
and,
due
to
such
disability,
is
permanently
confined
to
immediate
premises,
-or
A single
permanent
disability
evaluated
as
100-percent
disabling
and,
another
disability
evaluated
as
60
percent
or more
disabling.
A
veteran/widow
camiot receive
both
Aid
and
Attendance
and
Housebound benefits
at
the
same
time.
The
Tonn
of
Green/kid
is
an
Affiiaiati,e
Action/Equal
Opportunity
Enipiover,
a
designated
Green
Coinmuii
tip
and
a
recipient
oldie
Leading
hi’
Exan~ple
‘‘A
ward
Page 3
Understanding
the
Veterans Pension
Benefit
and
the
Aid
and
Attendance
Allowance
Estimates
show
agoroximatelv
10
million
seniors
--
about
25%
of
all
geoole
over
65
--
could
cualify
for
Pension
or
Death
Pension by
meeting
the
tests
outlined
in
this
fact
sheet.
That’s
how
many
war
veterans
or
their
surviving
spouses or
their
living
spouses
there
are
in
this
country.
Unfortunately,
few
people know how
to
get this benefit
and
currently
only
about
543,000
individuals
are
actually
receiving
it.
This
represents
only
5.4%
of
those
who
could
be
eligible.
What
is
Pension
and
Aid
&
Attendance?
Disability
Pension
and
Death
PensiOn
are
disability
income
VA
programs
available
to
veterans
or
to
the
single
surviving
spouses
of
deceased
veterans.
The
veteran
had
to
have served
on
active
duty
at
least
90
days
with
one
of
those
days
during
a
period
of
war.
Service
in
combat
is
not required, only
that
the
veteran
was
in
the
service
during
wartime
and
was
discharged honorably.
Charts
showing
the
available
amount
of
income
and
the
dates
for wartime
service
are
included below.
There
is
a
sister
benefit
to
Pension
called
Compensation.
This
is
for
veterans who
are
disabled
because
of
injuries
or
illnesses
incurred
while
on
active
duty.
Compensation
is
generally
the
more
desirable
benefit
for
a
number
of
reasons
we
will not
go
into
here.
A
veteran
household
cannot
receive
Pension and
Compensation
at
the
same
time.
A
decision
must
be
made
as
to
which
benefit
is
better
and
the
veteran
must
choose
only
that
benefit.
Period
of
Beginning
and
Ending
Dates
War
World
War
December
7,
1941
through
December
31,
1946
11
Korean
June
27,
1950
through
January
31,
1955
Conflict
Vietnam
August
5,
1964
through
May
7,
1975;
for
veterans
who
served
“iii
country”
Era
before
August
5,
1964,
February
28,
1961
through
May
7,
1975
Gulf
War
August
2,
1990
through
a
date to
be
set
by
law
or
Presidential
Proclamation
The Special
Case
for
Long
Term
Care
Costs
A
special
provision
for
calculating
Pension
income,
allows
household
income
to
be
reduced
by
12
months
worth
of future,
recurring
medical expenses.
Normally, income
is
only
reduced by
medical expenses
incurred
in
the month
of
application.
These
allowable,
annualized medical expenses
are
such
things
as
insurance
premiums, the
Updated
12/29/17
Page 4
cost
of
home
care,
the
cost
of
paying
any person
to
provide
care,
the
cost
of
adult
day
care,
the
cost
of
assisted
hying
and
the
cost
of
a
nursing
home
facility.
In
most
cases,
these
expenses are
only
deductible if
there
is
a
rating.
This
special
provision
can
allow
veteran
households
earning
more
than
the
annual
MAPR
to
qualify
for
Pension.
As
an
example,
a
veteran
household
earning
$6,000
a
month
could
still
qualify
for
Pension
if
the
veteran
is
paying
$4,500
to
$6,000
a
month
for
nursing
home
costs.
The
applicant
must
submit
appropriate
evidence
for
a
rating
and
for
recurring
costs
in
order
to
qualify
for
this
special
provision.
VA
normally
does
not
tell
applicants
about this
special
treatment
of
medical expenses
or
how
to
qualify
for
it.
For
an
explanation
of
the
special
annualized
treatment
of
unreimbursed
long
term
care
costs and
insurance
premiums
please go
to
the
article
entitled
“Understanding
the
special
case
of
long
term
care medical
costs’.
Dealing
with
Assets
That
May
Disqualify
the
Applicant
There
is
also an
asset
test
to
qualify
for
Pension.
Any
asset
or
investment
that
could
be
easily
converted into
income
might
disqualify the
claimant.
An
asset
ceiling
of
$80,000
is
often
cited
in
the
media
as
being
the
test.
The $80,000
has
to
do
with
VA
internal filing
requirements
and
is
not
an
actual
test.
In
reality,
there
is
no
dollar
amount
for
the
test
and
any
level
of
assets
could
block
the
award.
The asset
test
ultimately
becomes
a
subjective
decision
made by
the
veterans
service
representative,
processing
the
application.
A
home,
used
as
a
residence,
vehicles
and
difficult-to-sell
property
are
generally
excluded
from
the
asset
test.
The
Rating
A
rating
for
‘aid
and
attendance”
or
“housebound’
allows
VA
to
pay
additional benefits
beyond
the regular
Pension
benefit
ceiling
in
order
to
help
cover
the additional
costs
associated
with
added
disabilities.
A
rating
for
these
allowances
is
determined
by
a
veteran
service
representative
who
has been
trained
to recognize
from
medical
reports
and
interviews
whether
the
veteran
or
his
surviving
spouse
needs
the
additional
care.
Determinations
of
a
need
for
aid
and
attendance
or
housebound
benefits may
be
based
on
medical
reports
and
findings
by
private
physicians
or
from
hospital
facilities.
Authorization
of
aid
and
attendance
benefits
without
a
rating
decision
is
automatic
if
evidence establishes
the
claimant
is
a
patient
in
a
nursing
home.
Aid
and
attendance
is
also
automatic
if
the
claimant
is
blind
or nearly
blind
or
having
severe
visual
problems.
According
to
38
CER
Part
Three,
the
following
criteria
are
used
to
determine
the
need
for
aid
and
attendance:
o
inability
of claimant to
dress
or undress
himself
(herself),
or
to
keep
himself
(herself)
ordinarily
clean
and
presentable;
frequent
need
of
adjustment
of
any
special
prosthetic
or
orthopedic
appliances
which
by
reason
of
the particular disability
cannot
be
done
without
aid
(this
will
not
Updated
12/29/17
Page 5
include
the
adjustment
of
appliances which
normal
persons
would
be
unable
to
adjust
without
aid,
such
as
supports,
belts,
lacing
at
the
back,
etc.);
•
inability
of
claimant
to
feed
himself (herself)
through
loss
of
coordination
of
upper
extremities
or
through extreme
weakness;
•
inability
to attend to
the
wants
of
nature;
•
or incapacity,
physical
or
mental,
which
requires
care
or
assistance
on
a
regular
basis
to
protect
the
claimant
from
hazards
or
dangers
incident
to
his
or
her
daily
environment.
Not
all
of
the
disabling
conditions
in
the list
above
are
required
to
exist
before
a
favorable rating
may
be
made.
The
personal
functions
which
the
veteran
is
unable
to
perform
are
considered
in
connection
with
his
or
her
condition
as
a
whole.
It
is
only
necessary
that
the evidence
establish
that
the
veteran
is
so
helpless
as
to
need
regular”
(scheduled
and
ongoing)
aid
and
attendance from
someone
else,
not
that
there
be
a
24-hour
need.
‘Bedridden”
is a
definition
that
allows
a
rating
for
aid
and
attendance
by
itself.
“Bedridden”
is a
condition
which
requires
that
the
claimant
remain
in
bed.
A
person
who
has
voluntarily
taken
to
bed
or
who
has
been
told
by
the
doctor
to
remain
in
bed
will
not
necessarily receive
the
favorable
rating
for
aid
and
attendance.
There
must
be
an
actual
need
for
personal
assistance
from
others.
Housebound
means
“permanently
housebound
by
reason
of
disability
or
disabilities.”
This
requirement
is
met
when
the
veteran or
his
or
her
widow
is
substantially
confined
to
his
or
her
dwelling
and
the
immediate
premises
or,
if
institutionalized,
to
the ward
or
clinical
area, and
it
is
reasonably
certain
that
the
disability
or
disabilities
and
resultant
confinement
will
continue
throughout
his
or
her
lifetime.
A
person
who
cannot
leave his
immediate
premises
unless
under
the
supervision
of
another
person
is
considered
housebound.
This
might
include
the
inability to
drive
because
of
the
disability.
A
housebound
rating
does
not
mean
a
person
needs
to
be
confined
to
a
personal
residence.
It
can
apply
to
any
place
where
the
person
is
living
whether
in
a
facility
or
in
the
home
of
someone
else.
In
order
to receive
one
of these
ratings
the
claimant must
schedule
an
exam
with
his
or
her
physician
and have
the
physician
complete
VA
Form
21-2680.
This
Examination
for
Housebound Status
or
Permanent
need
for
Regular
Aid
and
Attendance
is
then
included
with
the
initial
application.
We
also
provide
in
our
book
a
supplemental
form
entitled
“Form
12
--
Statement
of
Attending
Physician
(used
to determine
rating
for
AM
or
HB).’
This
document
is
similar to
a
form
used
internally
by
VA
to
obtain
information
from
veterans
medical
facilities
for
determining
a
rating.
It
is
in
a
format that
a
veterans
service
representative would
recognize.
Medical
evidence
for
a
rating
for
“aid
and
attendance”
or
“housebound”
for
living
arrangements other than
a
nursing
home should
be
submitted with
the
application
to
avoid
a
delay
in
the approval
process.
Waiting
for
the
regional office
to order
medical
Updated
12/29/17
Page 6
records
is
a
time-consuming
process,
main’y
because
doctors’
offices
dont
respond
quic[dy
to
these
kinds
of
requests.
Updated
12/29/17
Page 7
Using
Aid
&
Attendance
to
Pay
any Person
for
Home
Care
Most people
who
have
heard
about
Pension
know
that
it
will
cover
the
costs
of
assisted
living and,
in
some
cases,
cover
nursing home
costs
as
well.
But
the
majority
of
those
receiving
long
term
care
in
this country
are
in
their
homes. Estimates
are
that
approximately
700/c
to
80%
of
all
long
term
care
is
being
provided
in
the
home.
All
of
the information
available
about
Pension
overlooks
the
fact that
this beneflt
should
be
used
to
pay
for
home
care.
Maybe
if
more
people
knew
this
fact,
more
people
would
be
applying
for
the
benefit.
It
also
comes
as
a
surprise
to
most
people
that
VA
will
allow veterans’
households to
deduct the
annual cost
of
paying
any
person such
as
family
members, friends
or
hired
help
for
care
when calculating
the
Pension
benefit.
This annual
cost
is
then
used
to
calculate
the benefit
based
on
a
new
“countable income”
and
allows
families
earning
more
than
the
pension
benefit
to
receive
a
disability
income
from
VA.
This
extra
income
can
be
a
welcome
benefit
for
families
struggling
to
provide
eldercare
for
loved
ones
at
home. Under
the
right
circumstances,
this
annualized
medical
expense
for
the
cost
of family
members,
friends
or
any
other
person
providing
care,
could
create
an
additional
household income
of
up
to
$1,153
a
month
for
a
singe
surviving
spouse
of
a
veteran,
up
to
$1,794
a
month
for
a
single
veteran
or
up
to
$2,127
a
month
for
a
couple.
If
the
disabled care
recipient
has been
rated
“housebound”
or
in
need
of
“aid
and
attendance”
by
VA,
all
fees
paid
to
an
in-home
attendant
will
be
allowed
as
long
as
the
attendant
provides
some
medical
or
nursing
services
for
the
disabled person. The
attendant
does
not
have
to
be
a
licensed
health
professional.
Services
of
licensed
home
care
providers
can
be
deducted
without
any need
for
a
rating
but
the
pension
award
is
a
lesser
amount.
It
is
our
understanding
that
a
non-licensed
in-home
attendant
could
be
just
about
anyone
receiving
pay
for
providing
services. This
might
be
members
of
the
family,
friends,
or someone
hired
to
live
in
the
home.
Examples
of
medical
or
nursing
services
would
be
help
with activities
of
daily
living
such
as
dressing,
bathing,
toileting,
ambulating,
feeding, diapering
and
so
on.
Other
services
might
include
medication
reminders
or
supervision
necessary
to
provide
a
protective
environment for
the
care
recipient
--
in
the
case
of
dementia
or
Alzheimer’s.
All
reasonable
fees
paid
to
the
individual
for
personal
care
of
the
disabled
person
and
maintenance
of the
disabled
person’s
immediate
environment
may
be
allowed. This
includes
such
services
as
cooking
and
housecleaning.
It
is
not
necessary to
distinguish
between
“medical”
and
“nonmedical”
services. Services
which
are beyond
the
scope
of
personal
care
of
the
disabled
person
and
maintenance
of
the
disabled person’s
immediate
environment
may
not
be
allowed.
This
might
include
paying
the
bills,
providing
transportation for
other
family
members, cooking
and
cleaning
for
other
family
Updated
12/29/
17
Page 8
members,
providing
entertainment,
providing
transportation for
personal
needs
other
than
medical
and
so
on.
For
a
disabled
person
who
has
been
rated,
a
family
member
may
be
considered
an
in-
home
attendant,
but that family
member
has
to
be
paid
for
services
duly rendered.
There
is
potential
for
fraud
here
where
a
family
member
may
move
into
the
home
and
ostensibly
receive
payment
as
a
caregiver
but
not
actually
provide
the
level
of
care
paid
for.
Documentation
for
this
care
must
be
provided
to
VA,
and
it
is
reasonable
for
VA
to
question
whether
the
services being
purchased
from
a
family
member
living
in
the
household
are
legitimate.
Such
arrangements
should
be
extensively documented
and
completely
arms-length.
The
care
arrangements
and
payment
must
be
made
prior to
application
and
there
must
be
evidence
that
this
care
is
needed
on
an
ongoing
and
regular
basis.
We
recommend
a
formal
care
contract
and
weekly
invoice
billing
for
services.
Money
must
exchange
hands
and
there
must
be
evidence
of
this.
All
of
this
documentation
must
be
provided
as
proof
to
VA
when
making
application
for
the
pension
benefit.
Costs
for
these
services
must
be
unreimbursed;
meaning
these
costs
are
not
paid by
insurance,
by
contributions
from the family
or
from
other
sources.
Let’s
look
at
the following
example.
Michelle,
who
is a
divorced
mother
of
two
teenagers,
moves
in
with
her
mother.
Michelle’s
mother,
Carla, has
recently
had
a
stroke
and
needs
supervision
and
help.
In
order to
take
care
of
her
mother,
Michelle
cannot maintain full
employment
outside
of
the
home.
She
has
found
a
company
that
will
let her
work
at
home
on
her
computer but
it
is
not
full
time employment
and
it
does
not
pay
well.
Michelle
has
expenses
she
needs
to
cover
for
existing
debts and
to
support
her
two
teenage
children.
She
does
not
have
housing
costs
but
does
consume additional
food
and
utilities
resources due
to
her
presence
and
her
children
being
in
the
home.
She
also
incurs
transportation
costs
for
her
car,
running
errands,
shopping
for
the
household,
taking
Carla
to
doctor’s
appointments
and
transporting
her
children.
Carla’s
household income
is
$1,400
a
month
which consists
of
Social
Security
and
a
small
Pension.
She
has
about
$20,000
in
savings
in
the
bank.
She
owns
her
home
and
a
car.
Michelle’s and
Carla’s
combined
income
is
just
not
enough
to
make
ends
meet
for
both
families.
Carla
is
the
single
surviving
widow of
a
Korean
veteran.
Michelle
has
heard
of
a
veterans benefit consultant
who
helps
families
in
this predicament
obtain the
Pension
benefit.
Michelle
meets
with the consultant
and
he
suggests
that
Michelle
and
her
mother
establish
a
contract
for
care and
that
Carla
pay her
daughter
$1,300
a
month
to
provide
care.
He
then suggests
submitting
a
claim
for
a
Death
Pension
for
Carla.
The
consultant
makes sure
a
legitimate
arm’s-length
agreement
is
written
up
and
that
the
care
services
and
payments
to
Michelle are
accurately
documented.
In
order
for
these payments
to
Michelle
to count towards
a
Pension
award,
Carla
must
have
a
rating
from
the
VA
for
“aid
and
attendance”
or
“housebound.”
The
consultant
provides
forms
and
advice
to
guide
Michelle
and
her
mother through the
application
process.
He
makes
sure
that
all
of
the
required
documentation
is
in
place
before
the
Updated
12/29/
17
Page 9
application
is
submitted.
He
reviews
all
documentation
and
the
completed
form,
which
Michelle
and
her
mother
have
filled
out, before
final
submission.
For
information
on
ratings
please
go
to
the
article
entitled
“Who
is
eligible
for
the
aid
and
attendance
Pension
benefit?’
If
VA
allows
annualization
of
the
cost
of
the
care
contract
in
calculating
the
Pension
benefit,
Michelle’s
mother
should
receive
an
award.
In
calculating
Pension,
Michelle’s
$1,300
a
month
contract
payment
should
be
annualized
and
subtracted
from
her
annual
income.
An
additional
medical
deduction
is
included
for
Carla’s
$200
a
month payments
for
Medicare
Part
B,
Medicare Part
D
and
a
Medicare
supplement
policy.
This
additional
amount
should
be
annualized
and
also
subtracted
from
Carla’s
income.
Both
the
contract
payments
and
the
insurance premiums
are
adjusted
for
S%
of
MAPR
before
being
subtracted
from
Carla’s
income.
Her
new
“countable”
income
will
be
negative
and
subtracting
that
new
income
from
the
MAPR
will
allow
Carla
to
receive
the maximum
Pension
benefit
for
her
rating
category.
For
an
explanation
of
the
special
annualized
treatment
of
unreimbursed
long
term
care
costs and
insurance
premiums
please go
to
the
article
entitled
“Understanding
the
special
case
of
long
term
care medical
costs”.
After
five
months,
VA
awards
Carla
$1,153
a
month
in
additional
Pension
income.
Her
total
income
is
now
$2,333
a
month.
VA
also
awards
a
total
of
four
months
of
benefit,
payable
retroactively
to
the
first
day
of
the month
following
the
mqnth
in
which
the
application
was
received
in
the
regional
office.
Condusion
Depending
on
household
income
and
the
amount
of the
care
contract
and
the
amount
of
VA
Pension
income,
these types
of
care
arrangements
could
be
a
welcome
addition
for
families
struggling
to
provide
care
for their
loved
ones
at home.
Family
care
providers,
on
contract
with
their
loved
ones,
do
not
have
to
be
residing
in
the
home.
Caution should
be
exercised
that
these
are
indeed
legitimate
contracts
and
care
provider arrangements
and
there
are
no
behind-the-scenes
transfers
of
monies.
Updated
12/29/17
Page 10
Using
Aid
&
Attendance
for
Professional
Home
Care
Annualization
of
Home
Care Casts
Medical
expenses
for
home
care
aides
are
allowed
prospectively
for
annualization
if
those
expenses
are
reasonably
predictable.
The
evidence would
also
have
to
show
that
the
need
for
care
is
ongoing
and
regular.
Expenses
may
be
allowed
whether
the
care
recipient
has
a
rating
for
aid
and
attendance
or
housebound
or
is
not
rated. However,
deductible
payments
to
a
non-rated
beneficiary
are
more
restrictive.
Evidence
must
be
submitted
indicating
an
ongoing
need
for
the
care
and
the
level
of
care
in
order
for
the Veterans
Service
Representative
to
consider the
medical expense
as
recurring
and
eligible
to
be
annualized.
A
form
such
as
the
one
we
provide
in
our
block
entitled
‘Form
2
--
Care
Provider
Report (used
to
provide
evidence
of
recurring
medical
expenses)”
should
be
used
for
this
purpose.
Also
a
copy
of
a
contract
between
the provider
and
the
recipient,
covering
at
least
a
year,
and
outlining
the
provisions
and
the
cost
should
be
submitted
to
prove
the
intent
of
the
care
recipient
and
the
provider.
For
an
explanation
of
the
special
annualized
treatment
of
unreimbursed
long
term
care
costs
and
insurance
premiums
please go
to
the
article
entitled
“Understanding
the
special
case
of
long
term
care medical
costs”.
The
non-veteran
spouse
of
a
living
veteran
may
also
be
eligible
for
annualization
of
home
health
aide costs.
If
the
home
care
is
being
furnished
by
a
licensed
health
professional,
then
not
much
further
proof
is
necessary
other
than
the
documentation
proving the
care
is
being
provided.
If
the provider
is
not
licensed,
a
separate
letter
from
the doctor
must
be
produced
that
says
the
person
needing
care
must
be
in
a
“protected
environment.”
VA
will not
rate
a
non-veteran
spouse
of
a
living
veteran
for
“aid
and
attendance”
or
“housebound”
and
even
though
the
spouse’s
home
care
medical expenses
may
be
annualized
to
produce
a
benefit, the
Pension
award
will
be
much
smaller
without
the
allowance
for
a
rating.
Of
course,
a
death
claim
is
different
because
the
surviving
spouse
can
receive
a
rating
in
that
case.
For
information
on
ratings
please
go
to
the
article
entitled
“Who
is
eligible
for
the
aid
and
attendance
Pension
benefit?’
Home
Care
Recipient
Is
Not
Rated
Payments
for
care
at
home
for
a
recipient
who
is
not
rated
for
housebound, or
aid
and
attendance
are
only
allowed
for
annualization
if
made
to
a
licensed
health
professional.
The
term
“licensed health
professional”
refers
to
an
individual
licensed
to furnish
health
services
by
the
state
in
which the
services
are
provided.
The
term
includes
registered
nurses,
licensed
vocational
nurses
and
licensed
practical
nurses.
Some
states
also
license
non-medical
home
care
providers
to
provide
services
as
well.
Since
this
is
a
fairly
new practice, we
don’t
know
if
these
people
would
qualify
under
the definition
above
but
we suspect
they
will.
Updated
12/29/17
Page 11
All
reasonable
fees
paid
to
the
licensed
health professional
for
personal
care
of
the
disabled
person
and
maintenance
of
the
disabled
person’s
immediate
environment
may
be
allowed,
This
includes
such
services
as
cooking
for
the
disabled
person and
housecleaning
for
the
disabled person.
It
is
not
necessary
to
distinguish
between
“medical”
and
“nonmedical”
services.
However,
services
which
are beyond
the
scope
of
personal
care
of
the
disabled
person
and
maintenance
of
the
disabled
person’s
immediate
environment
may
not
be
allowed.
Services
beyond
the
scope
might
be
services
such
as
driving
the veteran’s
spouse
to
appointments,
paying
bills,
answering
the
phone,
providing
shopping
errands
for
the
household,
and
so
on.
If
an
hourly
rate
is
being
paid
to
the
home
care
provider,
a
portion of
this
rate
may
be
disallowed
for
services
beyond
the
scope
of
personal care.
Care
Recipient
Is
Rated
for
“Aid
and
Attendance”
or
“Housebound”
If
the
disabled
care
recipient
has been
rated
“housebound”
or
in
need
of
“aid
and
attendance”
by
VA,
all
fees
paid
to
an
in-home
attendant
will
be
allowed
as
long
as
the
attendant
provides
some
medical
or
nursing
services
for
the
disabled person. The
attendant
does
not
have
to
be
a
licensed
health
professional.
All
reasonable
fees
paid
to
the
individual
for
personal
care
of
the
disabled
person
and
maintenance
of
the
disabled
person’s
immediate
environment
may
be
allowed.
This
includes
such
services
as
cooking
for
the
disabled
person
and
housecleaning
for
the
disabled
person.
It
is
not
necessary
to distinguish
between
“medical”
and
“nonmedical”
services.
However,
as
with
an
unrated
beneficiary,
services
which
are
beyond
the
scope
of
personal
care
of
the
disabled
person
and
maintenance
of
the
disabled
person’s
immediate
environment
may
not
be
allowed.
For
a
disabled
person
who
has been
rated,
a
family
member
may
be
considered
an
in-
home
attendant,
but
that
family
member
has
to
be
paid
for
services
duly rendered.
There
is
potential
for
fraud
here
where
a
family
member may
move
into
the
home
and
ostensibly
receive
payment
as
a
caregiver
but
not
actually
provide
the
level
of
care
paid
for.
Documentation
for
this
care
must
be
provided
to
VA,
and
it
is
reasonable
for
VA
to
question
whether
the
services being
purchased
from
someone
living
in
the
household
are
legitimate.
Documentation
of
Home
Care
Expenses
If
the
fees
for
an
in-home
attendant
are
an
allowable
expense, receipts
or
other
documentation
of
this
expense
are
required. Documentation
includes
any
of
the
following:
1.
a
receipt
bill
2.
statement
on
the
provider’s
letterhead
3.
computer
summary
4.
ledger, orbank
statement.
The
evidence
submitted
must
include:
1.
the amount
paid
Updated
12/29/
17
Page 12
2.
the
date
payment
was
made
3.
the
purpose
of
the payment (the
nature
of
the
product
or
service
provided)
4.
the
name
of
the
person
to
or
for
whom
the
product
or
service
was
provided
5.
identification
of
the provider
to
whom
payment
was made.
Updated
12/29/
17
Page 13
Using
Aid
and
Attendance
to
Pay
for
a
Nursing
Home
The
Easiest and
Most
Difficult
Application
For
a
potential
beneficiary
in
a
nursing home,
the application
for
Pension
with
Aid
and
Attendance
is
very
straightforward.
For
Veterans
The
claimant
simply
has
to
file
VA
Form
21p-527ez
and
indicate
that
he
or
she
is
a
patient
in
a
nursing home
on
VA
Form
21-0779
(for
a
veteran
in
skilled
nursing)
or
VA
Form
21-2680
and
a
Care
Provider
Statement
(for
a
veteran
in
intermediate
care).
An
award, including
an
aid
and
attendance
allowance from
VA,
is
almost
always
forthcoming
without
any
additional requirements relating to
a
rating.
Nursing
home
costs
are
also
automatically
annualized.
The
veteran must
also
submit
service
records
and
meet
VA’s
income
and
asset
requirements.
For
Surviving
Spouses
The
claimant must
file
VA
Form
21p-534ez
and
indicate
that
he
or
she
is
a
patient
in
a
nursing
home
using
a
detailed
Care
Provider
Statement
and
certify
a
need
for
the
aid
and
attendance
of
another
person
via
VA
Form
21-2680.
The
surviving
spouse
must
also
submit
the
veterans
service records,
a
marriage
certificate,
a
death
certificate,
and
meet
VA’s
income
and
asset
requirements.
Pension
or
Medicaid
While
in
a
Nursing
Home
Unfortunately,
in
most
cases, Pension
does
not
work
well
for
paying
the
costs
of
a
nursing
home.
This
is
because
the
amount
of
Pension
income
is
rarely
enough
to
cover
the
difference
between
the
cost
of
the
nursing home
and
the
beneficiary’s income.
On
the
other
hand,
Medicaid
will cover
this
difference
in
cost
and
in
most
cases
Medicaid
is
a
better
alternative to
Pension.
Eligibility
for
Medicaid
causes
difficulty
for
those
beneficiaries
who
also
want
to
receive
Pension
income
in
a
nursing
home.
For
a
single person,
VA
refuses
to
pay
the
full
Pension
benefit
if
that
person
is
eligible
for
Medicaid
and
will
only
pay
$90
a
month
towards
nursing
home
costs.
For
a
beneficiary
with
a
spouse
at
home,
the
combination
of
Pension
and Medicaid
may
not work
due
to
Medicaid rules.
There
are,
however, circumstances where
Pension
fits
very
well
for
a
beneficiary
in
a
nursing
home.
One
case
would
be
where
the
nursing
home
patient
has
to go
through
a
spend
down
in
order
to
be
eligible
for
Medicaid.
Pension
would
also
be
beneficial
where
the
nursing
home
patient
is
strictly private-pay
or
is
private-pay
awaiting
an
available
Medicaid
bed.
And
in
some
cases,
Pension
and
Medicaid
together
might
be
a
better
alternative
where
there
is a
spouse
at
home. But
each
of
these
instances
is
specific
to
the
individual
circumstances.
Updated
12/29/
17
Page 14
As
easy
and
simple
as
the
Pension
application
for
a
nursing
home
patient
is,
claimants
should
always
seek
the
advice
of
a
consultant
who
understands
both
Medicaid
and
the
VA
benefit.
There
are
strategies
that
can
be
pursued
to
make
Pension
for
nursing
home
patients work
out
in
certain
cases.
But
most
people
can’t
solve
it
on
their
own
and
it
requires
an
expert to
make
the
combination
of
Medicaid and
Pension
successful.
Annualization
of
Nursing
Home
Costs
If
the
veteran
or
veteran’s
surviving
spouse
is
a
patient
in
a
nursing
home,
VA
should
automatically
allow
12
months
worth
of
nursing
home
costs
to
be
applied
as
medical
expenses. The
patient
will
also
automatically
receive
an
aid
and
attendance
allowance.
The expenses applied
are
out-of-pocket
costs
after
reimbursement.
For
an
explanation
of
the
special
annualized
treatment
of
unreimbursed
long
term
care
costs
and insurance
premiums
please
go
to
the
article
entitled
“Understanding
the
special
case
of
long
term
care medical
costs”.
An
annualized medical expense
deduction
can
be
allowed
for
unreimbursed
nursing
home fees
even
if
the
nursing home
is
not
be
licensed
by
the
state
to
provide
skilled
or
intermediate
level
care.
The
definition
of
a
“nursing
home”
for
purposes
of
the
medical
expense
deduction
is
not
the
same
as
the
definition
of
nursing
home
set
out
in
38
CER
3.1(z).
A
nursing
home
for
purposes
of
the
medical
expense
deduction
is
any
facility
which provides extended
term, inpatient
medical
care.
A
responsible
official
of
the
nursing
home
must
sign
a
statement
that
the
disabled
claimant
is
a
patient
(as
opposed
to
a
resident)
of the
nursing
home.
We
have
included
on
this
site
a
copy
of
a
VA
form
that
is
used
for
this
purpose.
It
is
called
“VA
Form
21-
0779
--
Request
for
Nursing Home
Information
in
Connection
with
Claim
for
Aid
and
Attendance.”
A
copy
of
the
contract
with the
facility
should
also
be
included when
submitting
this
form.
Statements
and
evidence
of
payment must
also
be
included.
Canceled
checks are
not
acceptable.
Veterans
in
State
Veterans
Homes
may
apply
their
out-of-pocket
costs
for
use
of
the
home
as
a
recurring
prospective,
medical expense
deduction.
Again,
a
statement
from
an
official
of
the
state
home
indicating
the veteran
is
a
patient,
not
a
resident, should
be
submitted.
In
the
case
of
a
non-veteran
spouse
in
a
nursing home,
where
the
veteran
is
still
alive,
the
VA
application 21-527ez
does
not
have
a
provision
for
disclosing the
spouse
receiving
nursing home
care.
The
spouse
nursing
home
cost
is,
however, eligible
for
annualization
of
medical
expenses. Separate evidence
must
be
provided.
A
veteran
in
a
nursing home will receive
a
rating
for
aid
and
attendance,
but
the
non
veteran
spouse
of
a
living
veteran
will not,
Of course,
a
death
claim
is
different
because
the
surviving
spouse
can
receive
a
rating
in
that
case.
If
VA
allows annualization
of
nursing
home
costs
for
a
non-veteran
spouse
of
a
living
veteran,
there
will
be rio
allowance
for
aid
and
attendance,
and
the
Pension
award
will
be
much
smaller.
Updated
12/29/
17
Page 15
Retaining
VA
Benefits
and
Imputed
Income
VA
wiN
not
pay
anything
more
than
$90
a
month
if
a
single veteran or single
surviving
spouse
is
eligible
for
Medicaid
covered
nursing
home
care.
State
veterans
homes
are
exempt
from
this
ruling.
The
most
VA
will
pay
to
offset
the
cost
of
a
nursing home
is
$2,127
a
month
for
a
couple,
$1,794
a
month
for
a
single
veteran
or
$1,153
a
month
for
the
single
surviving
spouse
of
a
veteran.
With
nursing
home
costs
ranging
from
$5,000-$7,000
a
month,
generally
the
VA
benefit
cannot
cover
the
difference
between
the
veteran
household
and
the
nursing
home
cost.
In
most
cases
there
is
a
deficit.
Medicaid
will
cover
the
actual
difference
between
the
Medicaid
beneficiary’s income
and
the
cost
of
the
nursing
home.
Medicaid
is
therefore
a
more
viable
benefit.
For
the
reasons
outlined
above,
many
practitioners
feel
that
trying
to
dovetail
Medicaid
with
VA
payments
is
not
a
useful exercise,
and
for
those
eligible
for
Medicaid,
applying
for
Pension
might
be
a
waste
of
time.
But
there
are
situations
where
Medicaid
may
be
available,
and
the
Pension
could
be
a
valuable
benefit
as
well.
We
offer
an
example
of
this
further
on
in
this
article
where
a
veteran,
going
through
spend
down
to qualify
for
Medicaid,
can
provide
more
income
that
might
be
used
for
the
spouse
at
home.
Or
Pension
income
can
be
used
to
lengthen
the
spend
down
process, and
if
the
veteran
dies
while
going
through
this
process,
valuable
assets have
been
retained.
Another
use
for
the
Pension
benefit
associated
with
nursing home
care
is
where the
single
veteran
or
surviving
spouse
might
be
eligible
for
Medicaid,
but there
is a
statewide
waiting
list
for
Medicaid
beds.
With
the
tightening
of
government
purse
strings,
this
situation
is
more likely
to
occur
in
the
future.
The
Pension
benefit
allows
the
veteran,
the
surviving
spouse
or
his
or
her
family
additional
money
to
cover
part
of
the
cost
of
private
pay
until
a
Medicaid
bed
becomes
available.
For
the beneficiary who
is
eligible
for
Medicaid
and
has
dependents at
home, sharing
the
Pension
with
Medicaid
may
be
more useful
than
allowing
Medicaid
to
pay
the
entire
bill. State Medicaid
programs
require
veterans to
apply
for
Pension
because
it
reduces
Medicaid’s
liability
for
the
cost.
Hypothetical
Case
Example (Veteran and
Spouse
--
Veteran
in
a
Nursing
Home)
Thi~
case
illustrates
the
maximum
benefit
available
to
a
sihgle
veteran
with
aid
and
attendance
allowance. Residency
in
a
nursing
home
automatically
includes
the
aid
and
attendance
allowance.
The case
was
spedfically
desiqned
to
illustrate
how
Medicaid
and
veterans
Pension
could
dovetail
in
pro
viding
more
ihcome. As
a
general
nile,
VA
Pension
does
not
work
well
with
Medicaid
unless
there
is
a
spend
down
as
fri
this
case
or
the
Updated
12/29/17
Page 16
nursing
home
has
no
Medkaid
beds.
If
Meth~aid
is available,
it
is
unlikely
that
VA
Pension
would
be needed.
*we
híghly
recommend
fri
cases
such
as
this
one
that
you
contact
a
consultant
who
is
proficient
hi
both
planning
for
VA
benefits and
hi
Medicaidp/ann/i
7g.
To
try
and
understand
what
the
best
solution
is
by
yourself
is
probably
not
possible
without
a
thorough
knowledge
of
both
Meckaid
and
Pens/of?.
John
is
84
years
old
and
is a
veteran
of
World
War
II.
He
did
not
serve
in
a
combat
zone. Mary,
his
wife,
is
79
years
old.
John
is
a
large
man
and
has
many
medical
problems.
He
takes
a
variety
of
expensive prescription
drugs
and
has
difficulty
attending
to
his
own
needs
without
help. Mary
is a
frail
woman
and has
difficulty
helping
him
get
out
of
bed, dress,
bathe
and
move
about.
John
also
suffers
from
mild
dementia
and
is
often
confused
and
Mary
is
concerned
about
leaving
him
alone.
It
is
difficult
for
John
to
leave
his
home
without
using
a
walker
and
an
aide
to
help
him.
John and
Mary
have
a
combined
income
of
$2,400
a
month
which
consists
of
Social
Security
for
both,
a
small
Pension
and
interest
income.
They
have
$66,000
in
retirement
savings
and
own
a
house
and
a
car.
They
also have
$120,000
available
to
them
as
a
reverse
mortgage
equity
line
of
credit
if
they
choose
to
exercise
this
option.
They
are
not required
to
pay
anything other
than
the
closing
costs
for
this
line
of
credit
as
long
as
one
or both
of
them
is
alive
and
living
in
the
home. In
other
words,
there
are
no
monthly
loan
payments. The
potential
line
of
credit
will grow
by
earning
6%
interest
as
well.
John
has
a
nasty fall
and
breaks
his
hip.
After
surgery,
a
hospital
stay
and
a
30
day
stay
in
a
nursing
home rehab
facility,
John’s
health
deteriorates
even
further.
Mary decides
she
cannot
care
for
him
at
home
and
after
being
told
by
several
assisted living
facilities
they
cannot
take
him,
she
finds
she
must
place
John
in
a
nursing
home.
Because
of
the
differential
in
cost
between
the
nursing home
and
their
income,
John
will
qualify
for
the improved
Pension
benefit with
an
aid
and
attendance
allowance
but
in
the
state
in
which
they
live,
he
will
also
qualify
for
Medicaid.
VA
will
not
pay
more
than
$2,127
a
month
in
Pension
that
could
be
applied
to
John’s
nursing
home
cost.
On
the
other
hand,
Medicaid
will
pay
the
much
higher
cost
between
the
nursing home
and
John’s income
in
lieu
of
the
VA
Pension
benefit.
Should Mary
worry
about
applying
for
the
Pension
benefit knowing
that
Medicaid
may
cover
the entire
cost
of
the
nursing
home
and
allow
a
guaranteed
spousal
income
as
well?
In
this
particular
example Mary
could come
away
with
more
money
for
her personal
needs
by
using
both
the
VA
benefit
and
Medicaid.
To
understand
why
the combination
of
the two
benefits
is
better
we
need
to
understand
how
Medicaid
works.
Suppose
John
and
Mary
do
not
have
the
VA
benefit.
Medicaid
will
not
start
paying
for
John’s
nursing
home
costs
until
he
has
spent
his
portion
of
the
family
assets
down
to
less
than
$2,000.
In
the
state
in
which
he
resides, John
is
responsible
for
spending
$33,000
of
their
$66,000
in
retirement
savings.
He
can
spend
this
on
anything
he
wants
Updated
12/29/
17
Page 17
but
in
this
case
the
money
needs
to
go
towards
the
nursing
home
or
he
wont
have
a
place
to
live.
John’s
income
is
$1,800
a
month
and
Mary’s
income
is
$600
a
month.
The cost
of
the
nursing home
is
$5,000
a
month.
John
must
pay
$3,200
a
month
out
of
his
$33,000
of
spend
down money
to
the
nursing home.
After
10
months
John
will
be
below $2,000
and Medicaid
will take
over
paying
the
$3,200
a
month.
Or Mary
could
take
whatever
income
she
needs,
perhaps
the
full
$2,400
a
month,
and
let
John
spend
the
$33,000
for
the
nursing
home
in
which
case
he
would
quality
for
Medicaid
in
about
6
months.
After
Medicaid
takes over,
John’s
income
must
go
towards
the
nursing
home.
In
addition
to
$600
a
month,
Mary
has
her
own
$33,000
and
she
also
has
access
to
$120,000
in
the
reverse
mortgage
which
if left
in
the
line
of
credit
will
not
count
against
John
quaflfying
for
Medicaid.
Medicaid
will
also
not
impoverish
Mary
completely
and
in
the
state
where
Mary
resides,
Medicaid
will
give her
back
$1,600
a
month
from
John’s
income
to bring her
income
to
$2,000
a
month.
This
is
called
the
“community
spouse
monthly
income
allowance”.
But
this
is
only available
after
John
has
spent
down
his
$33,000
and
qualifies
for
Medicaid.
Mary
has
to
live
on
something
else
in
the
meantime.
Now
let’s
suppose
that
Mary
helps
John
apply
for
the
VA
Pension
with
aid
and
attendance
and
Medicaid
at
the
same
time.
John
must
spend
his
share
of
the
assets
before
he
becomes
eligible
for
Medicaid.
As
John
goes
through
his
spend
down,
VA
will
also
provide
additional
money
for
this
period
of
time.
The
benefit
estimate
is
in
the
table
below.
Estimating
the
Pension
Benefit
with
Aid
and
Attendance
Allowance
.
Calculate
Pension
Total Family
Income Calculate
Countable
Income
~
Benefit
family
income
$2,400
family
income:$2,400
allowable
benefit;$2,127
plus
pension,
less
unreimburset
less
countable
benefit$2,127
medical$3,310
income~ $0
total
income
$4
419
countable
income
-$910
pension
benefit
$2
127
Please
note
that
VA
calculates
benefits
and
costs
on
an
annual
basis and
divides
by
12
John
and
Mary
have
an
additional
$2,127
a
month
to
use
for
income or
to
apply
to
the
nursing home
while
John
is
going
through
his
spend
down. Over
the
period
of
months
where
John
is
applying
his
spend down money,
this
is
an
additional
$10,800
to
$18,000
Updated
12/29fi7
Page 18
(depending
on
the
spend
down period)
that
they
have
that
wouldn’t
be
there
without
the
VA
benefit.
After
John becomes
eligible
for
Medicaid,
things
get
complicated.
Medicaid does
not
count
as
income
for
VA
purposes
but
VA
Pension
does
count
as
income
for
Medicaid
purposes.
Whether
the
combination
of
the
two
benefits
or
Medicaid
alone
is
better
must
be
considered case-by-case.
Such
things
to
consider
are
the
spousal
minimum
income
allowance
from
Medicaid
or
whether
Medicaid’s
payments
on
behalf
of
John
will
become
part
of
a
recovery
effort
by
the
state.
If
John
were
single,
the solution would
be
simple.
VA
quits
paying
all
of
its
benefits
except
for
$90
a
month
when
John
becomes
eligible
for
Medicaid.
When
John
dies,
Mary’s
lower
income
may
qualify
her
for
a
death
benefit
Pension
from
the
VA.
Updated
12/29/17
Page 19
Submitting
a
Claim
for
the
Veterans
Aid
and
Attendance
Pension
Benefit
Two
Types
of
Pension
Claims
As
mentioned
in
a
previous
article
on
this
site,
there
are
two
types
of
Pension
applications. The
first
of
these
are
applications
for
veteran
households
with
low
income
and
few
assets.
For
living
veterans
under
the
age
of
65,
medical evidence
must
also
be
submitted
for
proof
of
total
disability.
For
living
veterans,
age
65
and
older,
there
is
no
requirement
to
be
disabled.
Single
surviving
spouses
of veterans
also
have
no
requirement for
disability. These low
income
applications
may or
may
not
have
a
need
for
an
additional
rating
to
receive
an aid
and
attendance
or
housebound allowance.
The
second
type
of
application
is
one
where the
household
may
have
higher
income
and
assets
but
one
or
more
members
of
the
household
are
incurring the
high
costs
of
long
term
care.
These
costs
may
be
for
the
following
types
of
services:
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These
types
of
claims
require
medical
evidence
in
order
to
receive
a
rating
for
aid
and
attendance
or
housebound
allowances.
These
ratings
must
be
received
or certain
medical expenses associated
with
long
term
care
are
not
deductible from
income.
These
claims
also
warrant
special
treatment for
deducting
the
annual cost
of
care
from
household income.
This
requires
special
documentation
and
evidence.
Claims
for
this
second
type
of
application
are
the
subject
of
this website
and
this article.
Here
are
the
forms typically
associated
with
these
types
of
claims.
VBA
Form
21P-527ez
--
Veteran’s Application
for
Pension
(for
a
living
veteran)
VBA
Form
alp_53Lj
Application
for
Dependency
and
Indemnity
Compensation,
Death
Pension
and
Accrued
Benefits
by
a
Surviving
Spouse
or
Child
SF
180
--
Request Pertaining
to Military
Records
(Used
to
obtain
discharge
record)
VBA
Form
21-0779
--
Request
for
Nursing
Home
Information
in
Connection
with
Claim
for
Aid
and
Attendance
VBA
Form
21-2680--
Examination
for
Housebound Status
or
Permanent
need
for
Regular
Aid
and
Attendance
(Completed
by
Claimant’s
Physician)
Care
Provider
Certification
of
Services
--
Care
Provider Report (Completed
by
Claimant’s
Care
Provider
&
used
to
provide
evidence
of
recurring
medical expenses)
Updated
12/29/17
Page 20
Questions and
Answers
about
Pension
Claims
Who
can
submit
a
claim?
A
claim
is
submitted
by
the
veteran or
by
the
veteran’s
single surviving
spouse
in
the
case
of
a
death
claim.
A
duly
appointed
service
organization,
an
employee
of
the
local
regional
VA
office,
or
a
VA
approved
agent
may
file
a
claim
on
behalf
of
the
veteran
or
the
spouse.
A
claim
cannot
be
filed
with
a
general
or
durable
power
of
attorney.
The
application
will
be
sent
back
requesting proper
documentation
for
a
VA
power
of
attorney.
The
veteran must
sign
a
document
specifically
authorizing
a
power
of attorney
for
someone
to
submit
an
initial
claim
for
him.
Many
chagrined
children
with
a
state
authorized
durable power
of
attorney
have
submitted
claims
on
behalf
of
a
parent
only
to
have
the
claim
rejected
by
VA.
What
happens
if
the
veteran
is
incompetent?
If
the
veteran cannot
submit
the
original
application
or
sign
a
power
of
attorney
for
a
surrogate to
file
an
application,
then
a
duly
appointed guardian
can
complete the
application.
VA
also
allows
the
spouse,
a
parent
or
next
of
kin,
or
a
friend to
complete
and
submit
an
application
on
behalf
of
an
incompetent
veteran
if
that
person
submits
the
proper
power
of
attorney
request
and
indicates
the applicant
could
be
considered
incompetent
for
financial affairs.
Even
though
the
veteran
or
surviving
spouse
may
be
considered
incompetent
for
financial affairs,
he
or
she
must
always
sign
the
power
of
attorney
request if
he
or
she
is
can
physically
do
so. VA
may
appoint
a
fiduciary
to
take
over
the
the
financial
management
of
pension
funds
for
the
claimant
if
VA
determines
he
or
she
is
incompetent.
What
is
an
“aid
and
attendance”
or
“housebound”
rating?
A
“rating’
is
granted
by
a
veteran
service
representative where
a
condition
exists
that
requires
more
caregiver
support
for
the
disability.
Medical
evidence
is
required
unless
someone
is
a
patient
in
a
nursing
home,
and
then
the
requirement
is
waived.
The
rating
allows
VA
to
pay
an
additional
monthly
amount
of
Pension
or
Compensation
to
a
veteran
or
a
surviving
spouse
for
additional
costs
associated
with
this disability.
How
does
one
qualify
for
aid
and
attendance
or
housebound
rating?
The
application
form
has
a
block
allowing
for
a
request
for
either
rating.
Submitting
medical
evidence
in
advance
instead
of
waiting
for
a
request
from
VA
can
help
expedite
the
process
of
getting
this
rating.
Can
the
non-veteran
spouse
of
a
living
veteran
receive
a
rating
for
aid
and
attendance
or
housebound?
If
the
veteran
is
receiving
Compensation
and
is
at
least
30%
or
more
service
connected
disabled
there
is
an
allowance
available
if
the
spouse needs
aid
and
attendanceor
is
housebound.
An aid
and
attendance
or
housebound allowance
is
also
available
to
a
surviving
spouse receiving
DIC.
According
to
VA,
a
rating
is
not
available
to
the
non
veteran
spouse
of
a
living
veteran
for
Pension.
A
rating
is
available
to
the
single
surviving
spouse
for
death
Pension.
Updated
12/29/17
Page 21
What
documentation
is
required?
The
veteran
must
provide
an
original
copy
of
discharge
from
service,
typically
a
DD
214
or
a
WD.
A
photocopy
is
allowed
if
it
is
certified
by
a
government
agency
recognized
to
do
this.
This could
be
the
local
courthouse.
For
a
death
benefit,
a
death
certificate
must
be
furnished
as
well.
VA
may
request
copies
of
other
documents,
but,
generally,
providing
sufficient information
on
the
claim
form
will satisfy
the
need
for
other
documentation.
If
an
applicant
for
Pension
is
younger
than
65,
medical evidence
of
total
disability
must
also
be
submitted.
Total
disability
for
65
and
older
is
not
a
requirement
for
death
Pension.
What
is
the
effective
date?
The
effective
date
is
generally
the
day
VA
receives
an
original application.
If
it
takes
three
months
for
the
process
of
approval
or
six
months,
it
doesnt
matter.
The
effective
date still
reverts
to
receipt
of
the original application.
When
does
payment
begin?
Generally,
payments
start
on
the
first
day
of
the
month
following
the month
of
the
effective
date.
This
means
that
if
it
took
six
months
to get
approval,
at least
five
months
of
benefit
will
be
paid
retroactively.
VA
requires
automatic
deposit
of
awards
in
a
checking
or
savings
account.
What
happens
if
the
veteran
dies
during
the
period
of
application?
If
the veteran
dies
during
the
period
of
application
and
the
application
was
not
approved prior
to
the
death,
there
may
be
accrued
benefits.
If
the
regional
office
had
all
of
the
information
in
its
possession
that
would
have
led
to
an
approval,
then
there
is
an
accrued
benefit
payable.
Otherwise there
is
none.
The
full
benefit
is
available
up
to
the
month
of
death
of
the veteran
and
to
a
surviving
spouse
through
an
application
on VA
Form
21-0847
(REQUEST
FOR
SUBSTITUTION
OF
CLAIMANT
UPON
DEATH
OF
CLAIMANT).
If
a
claimant
dies
while
a
claim
or
appeal
for
any
benefit
under
a
law
administered
by
the
Secretary
is
pending,
a
living
person
who
would
be
eligible
to
receive
accrued
benefits
due
to
the
claimant
under
section
5121(a)
of
this
title
may,
not
later
than
one
year
after
the
date
of
the
death
of
the
claimant,
request
to
be
substituted
as
the
claimant
for
the
purposes
of
processing
the
claim
to
completion.
A
new
claim
for
death
pension
can
abs
be
started
using
VA
Form
21-534ez.
What
is
a
veteran’s federal
fiduciary,
and does
that
affect
the
application?
For
a
veteran
who
is
considered
incompetent
to
handle
his
own
financial
affairs,
VA
will
appoint
a
fiduciary
to
receive
the
money
and pay
the
bills.
A
federal
fiduciary
is
an
individual
appointed
for
this
purpose,
usually
a
spouse
or
a
family
member.
In
most
cases
--
except
for
the
spouse living
with
the
veteran
--
there
is
an
interview
required
and
paperwork.
This
process
can
take
a
long
time,
and
it
is
to
the
advantage
of
the
person
filing
an
original
claim to
request the
appointment
of
himself
or
herself
as
a
fiduciary
or
for
some
other appropriate
person
or organization
to
act
as
a
fiduciary
in
order
to
help
expedite
the
process.
VA
always
makes
the
final
decision
on
whom
it
appoints
as
a
fiduciary.
In
fact, the
agency
might
well
ignore
court
appointed fiduciaries.
In
general,
the
decision
favors
declaring
the
veteran
competent
and
avoiding
a
fiduciary
where at
all
possible.
Updated
12/29/17
Page 22
What
is
the difference between
Compensation
and
Pension?
Compensation
is
paid
for
service-connected
disabiNties;
whereas,
Pension
is
paid
to
veterans
who
are
disabled because
of
non-service-connected
causes.
Compensation
is
meant to
compensate
a
veteran
for
loss
of
income due to
the
disability.
Pension
is
meant to
provide
more
income
to
low
income, disabled,
active
duty
veterans who
served
during
a
period
of
war.
Which
benefit
is
better?
The
veteran
can
choose
the
larger
of
either
benefit
but
cannot
have
both.
If
the
veteran
is
receiving
military
retirement
or
has
received
other
reimbursement
related
to
military
service, those
monies
will
be
reduced
by
the amount
of
Compensation. There
are
special
rules
for
reducing
this
offset
for
veterans
who
are
500/c
or
more disabled.
Pension does
not
reduce
military
retirement.
For
veteran
families with
expensive home
care
services,
assisted
living, or
nursing home
costs,
Pension
is
could
be
the
larger
benefit.
Can
a
veteran apply
for
Compensation
years
after
leaving
the
military?
A
recent
survey
by
VA
found
that
a
large
percentage
of
older veterans
had
never
applied
for
Compensation
but
could
be
eligible
based
on
injuries
or illnesses
incurred
while
they
were
in
the service.
A
veteran
can
apply
for
these
benefits
at
any
time.
Agent
Orange
claims
and
PTSD
claims
are
in
this category.
Can
a
veteran receiving
Compensation
reapply
for
additional
income?
Many
veterans
are
receiving Compensation,
but
their
disability
related to service
may
have
become
worse.
They
can
apply
for
a
higher
disability
rating
and
thus
more
money
at
any
time.
There
are
also
additional
benefits
for
veterans
who
may
have lost
limbs,
eyesight,
hearing,
or
the
use
of
other
parts
of
their
body.
Can
a
veteran
receiving
military
retirement
pay
also
receive
Compensation?
A
veteran cannot
receive
Compensation
and
military
retirement
at
the
same
time.
Generally,
the
veteran
will
waive
a
portion
of
military
retirement that
equals
Compensation
because
retirement
is
taxable
and
Compensation
is
not.
Since
2004
military
retirees
with
a
VA
rated
disability
of
50%
or
more
are no
longer
being
required
to
waive
military
retirement
pay
to
receive
VA
disability
Compensation. This
new
law
is
being phased
in
over
a
9-year
period. However
military
retirees
with
a
VA
rated
disability
of
4O%
or
less
are
still
required
to
waive
a
portion
of
their
military
retirement
pay
to
receive
Compensation.
What
is
the
income
test
for
Pension?
If
the
household
income
adjusted
for
medical expenses
is
greater
than
the
maximum
allowable
Pension
rate
--
MAPR
-~
there
is
no
benefit.
In December
2013
-
December
2014,
the
maximum
allowable rate
for
a
couple
with
aid
and
attendance
allowance
is
$25,022
a
year.
For
a
single
veteran it
is
$21,107
a
year.
Without
aid
and
attendance
or
housebound
allowance
the
maximum
couple’s rate
is
$16,569
a
year
and
for
a
single
it
is
$12,652
a
year.
Death
Pension
rates
are
lower.
People
seeking
a
benefit with
adjusted
incomes
greater than
these
levels
will
be
denied.
Updated
12/29/17
Page 23
Can
a
household
with
income
above
the
maximum
limit
qualify?
A
special
provision
in
the
way benefits
are
calculated
can
allow
individuals
and
couples
earning
between
$24,000
to
$60,000
a
year
to
still
qualify
for
a
benefit.
It
has
to
do
with the
treatment
by
VA
of
the very
large
recurring
medical
costs
associated
with
home
care,
assisted
living,
or nursing
home
care.
What
is
the
Pension
household asset
test,
and
what
can
be
done
if
the
asset
test
is
not
met?
As
a
general
rule
assets
cannot
exceed
$80,000.
But
there
is
no
specific
test
in
the
regulations.
Veterans
service
representatives
are
requiredto
file
paperwork
justifying
their
decision
if
they
allow
assets
greater than
$80,000. Thus
this amount
has
become
a
traditional
ceiling.
The service
representative
is
encouraged
to analyze
the veteran’s
household
needs
for
maintenance
and
weigh
those
needs
against
assets
that
can
be
readily
converted
to
cash.
In
the
end,
the
decision
as
to
allowable
assets
is
a
subjective
decision
made by
a
service
representative. In
certain
cases
a
benefit
award could
be
denied
unless
assets
are
below $20,000 or
$10,000
or
even
zero
dollars.
What
proofs
and
documents
are
required
with
the
Pension
claim?
We have
already
discussed
the
requirements for
power
of
attorney
and
fiduciary
if
they
apply.
In
addition,
an
original
copy
of
the
discharge
from
service
--
typically
DD
214
or
form
WD
--
is
required
and
the
discharge
must
have
been
other
than
dishonorable.
If
there
is
a
question
about
the
marriage
relationship,
a
marriage certificate
or
other proof
may
be
necessary.
Birth
certificates
of
dependent
children
are
usually
not required
but
may
be
necessary
under
certain
conditions.
A
dependent
child
is
a
minor,
a
dependent
student
under
age
23,
or
a
totally
dependent adult
child.
There
are
certain
documents
that
need
to
be
submitted to
prove
future
recurring
medical
expenses
and
to
prove
need
for
aid
and
attendance
or
housebound allowances.
VA
does
not
furnish
these
documents
nor
provide
any
information
that
they
are
required.
Can
someone
charge
to
help
fill
out
the
form?
Federal
code
and
VA
regulations
prohibit
an
agent
or
attorney
from
charging
a
fee
to
fill
out
an
application prior
to
denial
of
an
appeal.
Some
practitioners or
providers
help
their
clients
for
free, sometimes
in
the
context
of
solving
other
retirement
issues
or
providing
long
term
care
services.
Some
practitioners
offer
advice
for
a
fee
but
will
send
their
clients
to
a
veterans’
service
organization
to complete
the
application.
Charging
a
fee
for
advice
not
related
to
assistance
with
a
claim
for
benefits
appears to
be an
acceptable
practice allowed
by
VA.
How
are
assets,
income
and
unreimbursed
medical
expenses
determined?
The
applicant
must
submit
details
on
the
application
of
all
income
and
all
assets
including
retirement
savings
accounts
such
as
IRAs.
Almost
any
type
of
money
received
or
anything
received
that
can
be
converted
into money
is
income.
The
only
exclusions
for
assets are
a
personal
residence
and
a
reasonable
amount
of
land
it
sits
on
as
well
as
vehicles
and
other
personal
possessions.
Personal
possessions
used
as
an
investment
such
as
a
coin
collection
are
counted
as
assets.
Unreimbursed
medical expenses
can
be
almost
any
expense
related
to
medical
needs.
Updated
12/29/17
Page 24
Are
there
any
other
reporting
requirements?
VA
requires
that
any
change
in
income
or assets
be
reported immediately,
The
award
is
calculated
for
12
months
in
advance,
but
at
the beginning
of
each
calendar
year,
a
formal
report
called
an
EVR
(eligibility
verification
report)
must
be
filed
detailing
all
income,
assets
and
unreimbursed
medical expenses
for
the
coming
calendar
year.
For
example
if
the
award
is
granted
in
April
for
12
months
in
advance,
an
EVR
must
be
submitted
in
January
of
the
next
year
that
could
affect
the
award
amount
for
the
remaining
four
months.
The
EVR
will
be
used
for
determining
benefits
for
the
calendar
year
on
which
it
is
based
and
possibly
adjusting benefits
already
received
or
even
demanding
repayment
for
overpayment
of
benefits.
Will
the
Pension
benefit
pay
a
non~llcensed
homecare
provider?
VA
does
not
pay
providers
directly but
provides extra
income
to
make
up
for
the
cost
of
medical
care
providers.
Medical
conditions
or
injuries
or
diseases
that
require
a
need
for
ongoing
homecare
will
allow
the applicant
to
reduce
household
income
by
the
cost
of
homecare making
it
possible
to
receive
the
additional
income
from
a
Pension
award.
If
the
beneficiary
has
an aid
and
attendance
or
housebound
allowance,
VA
will
pay
nonlicensed
providers.
Will
the
Pension
benefit
pay
a
member
of
the
family
to
provide
care
at
home?
As
explained
above,
VA
will not
pay
providers
directly but
only
indirectly
through
extra
income.
If
the beneficiary
receiving
care
in
the
home
has
received
a
rating
for
aid
and
attendance
or housebound,
VA
will
allow
expenses
paid
to
a
family
member
for
care
to
be
counted
as
unreimbursed
medical expenses
to
qualify
for
the benefit.
Does
the
Pension
benefit
pay
the
costs
of
a
nursing
home?
The
application
form
has
provision
for
indicating residency
in
a
nursing home
and
whether
or
not
the applicant
is
eligible
for
Medicaid.
VA
will
automatically
apply the
monthly
cost
of
the
nursing home
in
determining
the
Pension
benefit.
If
the
applicant
is
single
with
no
dependent
children
at home
and
is
eligible
for
Medicaid,
VA
is
required
to
stop
any
payment
of
benefits
and
only
provide
the
veteran
with
$90
a
month.
Does
the
Pension
benefit
pay
the
costs
of
assisted
living?
As
explained
above,
VA
will
not
pay
providers
directly but
only
indirectly
through
extra
income.
If
the beneficiary
receiving
care
in
assisted living
has
received
a
rating
for
aid
and
attendance
or
housebound,
VA
will
allow
expenses
paid
to
assisted
living
for
aid
and
attendance
or
housebound
including
room
and
board
to
be
counted
as
unreimbursed
medical
expenses.
The cost
of
assisted
living
being
used
as
a
retirement
residence
is
not considered
a
medical expense.
What
are
the
requirements
to
receive
a
Death
Pension
benefit?
The
applicant
must
be
a
surviving
spouse
or
a
dependent
child
of
an
eligible veteran.
VA
form
21-534ez
is
used
to
apply
for
death
Pension,
death
Compensation,
accrued
benefits,
or
dependency
and
indemnity
Compensation
(DIC).
The
surviving
spouse
must
be
single.
A
surviving
spouse
of
any
age
is
eligible
as
long
as
the
deceased
veteran
served
at
least
90
days
during
a
period
of
war. They
had
to
be
married
at
least
a
year
prior to
death or
have
a
child
as
a
result
of
the marriage.
There
is
no
requirement
for
Updated
12/29/17
Page 25
total disability
for
the
surviving
spouse nor
for
the
deceased
veteran
to
have
been
totally
disabled
or
older
than
age
65.
How
does
one
prove
that
unreimbursed
medical expenses
will
recur every
month?
VA
has
specific
rules
for
proving
future
recurring
medical expenses.
Information
in
our
book
outlines the
type
of
paperwork
that
must
be
submitted
for
each
type
of
long
term
care
service.
Neither
the
claims
form
nor
information
from the
regional
office
provides
any
guidance
on
the
rules
for
proving
future
recurring
medical expenses
for
home
care
or
assisted
living.
One
simply
has
to
know
how to
do
it.
What
if
the
veteran
or
spouse
is
currently
receiving
Medicaid?
Our
interpretation
of
the
rules
leads
us
to
believe
that
VA
will
not
consider
Medicaid
payments
as
income. However,
Medicaid
will
consider
the non-allowance
portion
of
the
Pension
to
be
income. This
could
affect
Medicaid
eligibility
in
income
test
states.
There
is
evidence
that
some
income
test
states
count
the
entire
Pension
benefit
including
the
allowance
as
income.
According
to
federal
Medicaid
rules
this
should
not
happen.
What
happens
when
the
veteran
or
spouse
wants
to
receive
Pension
&
Medicaid
together?
Federal law
requires
that
a
single veteran
receiving
Medicaid
with
no
spouse
or
dependent
children
can
receive
no
more
than
$90
a
month from
VA.
Veterans
in
state
veterans
homes are
exempt from this
requirement.
The
veteran
with
a
spouse
can
receive
the
benefit to
help
defray the
costs
of
a
nursing home.
As
a
general
rule,
the
Pension
benefit
would probably
not work
if
Medicaid
were
paying
the
bill.
But
the
benefit
does
work
well
for
non-Medicaid nursing
home
beds and
while the
recipient
is
going
through
the
Medicaid
spend
down.
We
highly
recommend
you
use
an aid
and
attendance
benefits
consultant
when
trying
to
make
Pension
and
Medicaid
dovetail
without
getting
into
trouble
with
Medicaid rules.
Medicaid
with
the
Aid
&
Attendance Benefit
Why
Aid
and
Attendance
Pension
Leads
to
Planning
for
Medicaid
If
the
person
receiving pension
is
also
receiving
home
care,
adult
day
care,
assisted
living
care
or
nursing
home
care
there
is
a
high
likelihood
that
Medicaid
may
become
part
of
the
planning
strategy
for
receiving
care.
The
application
for
aid
and
attendance
becomes
a
great
opportunity
to
examine
the
consequences
of
Medicaid
on
income
and
assets
prior to
the
need
for
applying
for
Medicaid.
Most
people
only
deal
with
Medicaid
when
they
reach
debt
crisis
moment
or
assets
or
income
or
insufficient
to
pay
for
existing
care.
Doing
some
planning
in
advance
may
allow
individuals
or households
to
save
some
assets
or
to
provide
more income
for
a
healthy
spouse.
This
planning may
also
allow
the
opportunity
to
preserve
the
home
from
Medicaid
recovery.
A
Brief
Description
of
Medicaid
Medicaid was
established
as
Title
IX
of
the
1965
Amendment
to
the
Social
Security
Act
while
Medicare
was
established
at
the
same
time
as
Title
VIII
of
the
Act.
Medicaid
is
a
health
insurance
program
for
certain low-income
people.
These
include: certain
low-
Updated
12/29/
17
Page 26
income
families with
chfldren;
aged,
(65
and
older)
blind,
or
disabled people
on
Supplemental
Security
Income;
certain
low-income pregnant
women
and
children;
and
people
who
have
very
high
medical
bills.
Medicaid
is
funded
and
administered
through
a
state-federal
partnership.
Although
there
are broad
federal
requirements
for
Medicaid,
states
have
a
wide degree
of
flexibility
to
design
their
programs.
States
have
authority
to
establish
eligibility
standards,
determine
what
benefits
and
services
to
cover,
and
set
payment
rates.
All
states,
however,
must
cover
these
basic
services:
inpatient
and
outpatient
hospital
services,
laboratory
and
X
ray
services,
skilled nursing
and
home health
services,
doctor’s
services,
family
planning,
and
periodic health
checkups,
diagnosis
and
treatment
for
children.
Funds
for
Medicaid
are
provided
jointly
by
the federal
government
and
the
states.
On
average,
the
federal
government
provides
about
57%
of
Medicaid
funds
and
the
states
provide
the
other
43%.
The
amount
of
shared
funding
varies
from
state
to state
depending
on
the
per
capita
income
in
each
state.
States
with
low
per
capita
income
such
as
Mississippi
receive
up
to 83%
of
their
Medicaid
funding
from the federal
government
and
the
state
provides
the
other
17%.
On
the
other
hand, states
with
high
per capita
income
such
as
Connecticut
share
Medicaid
funding
with
the
federal
government
on
a
SO%
to 50%
basis.
Long-term
care
recipients
of
Medicaid
come
almost
exclusively
from
the
aged,
blind
and
disabled
group
of
eligible
beneficiaries
but very
few
of
those
are
actually
receiving
SSI
(Supplemental
Security
Income).
SSI
is
a
welfare payment
for
certain
disabled
or
handicapped
individuals
who
are unable
to
work,
have
no
assets and
have
no
extended
family
financial
support.
Certain
provisions
of
the
enabling
Act,
as
well
as
congressional
amendments
since
1965
have
allowed
the
aged,
blind
and
disabled
who
dont
qualify
for
SSI
to
receive
Medicaid
under
an
alternate
set
of
eligibility
rules.
Currently
there
are
about
60
million
people
or
20%
of
the
US
population
receiving
Medicaid
support.
Most
of
these
people
are
receiving
various forms
of
health
care
services
and
are
younger
than
age
65.
Our
interest
lies
with
those
Medicaid
beneficiaries
who
need
long
term
care and
can
receive
help
from
Medicaid
to
pay
those
costs.
In
addition,
we
focus
aln9ost
exclusively
on
aged
long
term
care
beneficiaries
--
those
over
the
age
of
65.
Aged
long
term
care
Medicaid
beneficiaries
represent
about
7%
of
the entire
Medicaid
population
or
about
4
million
beneficiaries.
Out
of
these
long
term
care Medicaid
beneficiaries,
approximately
1
million
are
receiving
various
levels
of
Medicaid
funding
support
in
nursing
homes
and
approximately
3
million
are
receiving
some
form
of
home-
based
or
community-based
Medicaid long
term
care
support.
Even
though
elderly
long
term
care
beneficiaries
only
represent about
7%
of
the
Medicaid
population
they
account
for
about
19%
of
all
Medicaid
spending.
This
is
because
long
term
care
services
are
very
expensive,
particularly
those funds
used
for
nursing home
care.
Medical
Eligibility
for
Long
Term
Care
An
individual
must
go
through
an
evaluation
with
a
state
Medicaid
assessment
specialist
in
order
to
determine
a
need
for
care.
If
the
individual
fails
to
meet the
minimum
level
Updated
12/29/17
Page 27
of
care
needed
to qualify
for that
State’s
Medicaid
coverage, then
no
Medicaid
help
is
forthcoming.
A
need
for
skilled
nursing
care will
automatically qualify
a
person
in
any
state.
It’s
also
likely
that
a
candidate
already
in
a
nursing
home
but
not
needing
skilled
care
will still
qualify.
Skilled
care
must
be
needed
on
a
frequent
basis.
Examples
of
skilled
care
might
include
the
need
for:
frequent
monitoring
of vital
signs,
wound
dressing
changes,
maintenance
of
mechanical
ventilation
equipment,
maintenance
of
a
catheter,
help
with
elimination
problems,
maintenance of
IV
administrations,
careful
monitoring
of
medication
usage,
managing
colostomy
problems,
careful
supervision
of
severe
diabetes,
frequent
injections, maintaining
a
feeding
tube
and
many
more
problems
requiring
the
skill
of
a
nurse
or
doctor.
Medical
eligibility
for
home
and
community-based
services
could
be based on
different
criteria
from
those
for
nursing
homes;
but
in
some
states,
a
person
must qualify
for
Medicaid
based
on
the
nursing
home
eligibility
standards
in
order
to
receive
Medicaid
services
at
home
or
in
assisted
living.
Income
and
Asset Tests
There
is
both
an
income
and
an
asset
test
to
qualify
for
Medicaid long
term
care
services.
In
general,
these
tests
are
applied
for
nursing home
services
but
these
same
tests
may
also
be
used
to
qualify
individuals
for
home
or
community-based
Medicaid
services
as
well.
In
other
states
the
financial
requirements
for
community-based
services may
be
more
stringent
than
those
for
nursing
homes
or
they
may
be
less
stringent.
For
the elderly
and
people
with
disabilities
with long-term
care needs,
income
qualifying
levels
are
often tied
to
the
Supplemental
Security
Income
(551)
program—$674
per
month
in
2010
—but
income
limits
can
be
higher
in
states
that
have
more liberal
rules.
Most
states allow
the
“medically
needy”—those
with
large
medical
or
long-term
care
bills
--
to
deduct
these
costs
from
their
gross
income
to
reach
the
required
income
level
and
participate
in
Medicaid.
These
criteria
are
usually
quite
stringent
as
most
states set
their
medically
needy
income
level
at
or below
551
levels.
This deduction
from
income
can
happen
in
a
direct
manner
or
it
can
happen
indirectly
by
potential
beneficiaries
paying
in
a
so-called
‘co-pay’
for
their
share
of
the
services. This
co-pay represents
the
amount
of
income above
the
state
income
qualification
level.
This
medically
needy
program
is
optional
for
states, however,
and
15
states
(plus
the
District
of
Columbia)
do
not
have
medically needy
programs.
In
some
states
that
do
not
have
medically
needy
programs,
individuals
needing
nursing
home
care
can be
covered
under
the “300
percent
rule”.
Under
this option, individuals
with
income
up
to
300°k
of
SSI
($2,094
per
month
in
2012),
can
qualify
for
institutional
care.
Other
states
may have
more
stringent
income
rules
for
Medicaid
qualification.
In
states
that
apply
a
strict
income
rule,
individuals
having more
than
the
state income
limit
cannot
receive Medicaid
assistance regardless
of
their
expenses.
These
states
are
called
“income
cap
states.”
There
are
currently
22
income
cap
States.
Updated
12/29/17
Page 28
Under
the
Medicare
Catastrophic
Coverage Act,
income
cap
states
must
allow
those
individuals
with
incomes
above
the
cap
to
qualify
for
Medicaid
if
they
put
their
excess
income
in
a
trust
known
as
a
“Qualifying
Income
Trust.”
States are
allowed
to
recover
funds
in
the
trust
after
the
person’s
death.
Nursing home
residents
who qualify
as
medically
needy
or
through
the
300
percent
rule
must
apply
the
majority
of
their monthly
income
toward
the
cost
of
care,
thereby
reducing
the amount
that the
Medicaid
program
must
pay. Medicaid
nursing home
residents may
keep
only
a
small
personal
needs
allowance (between
$30-$90
per
month)
to
pay
for
items
that
are
not
covered
by
Medicaid,
such
as
clothing,
books,
toiletries, or
telephone
service.
Medicaid
beneficiaries
receiving
home
and
community
based
services are
also
required
to
apply
a
portion
of
their
income
to
the
cost
of
care,
although
states
may
allow
them to
retain
more
of
their
income
to
maintain themselves
at
home
than
if
they
were
in
an
institution,
where
Medicaid
covers room
and
board.
States
are
required
to
allow
nursing
home
residents
with
spouses
living
in
the
community
to
retain
a
certain
amount
of
income
for
the
support
of
the
community-
residing
spouse.
This
set-aside
for
the
healthy
spouse
at
home
avoids
impoverishing
that
spouse instead
of
using
all
of the
household
income
for
nursing
home
costs.
States
may
set
their
own
income
limits
for
this
spousal
allowance
but
must
allow
a
community
spouse
to
keep
between
$1,838.75
and
$2,841
per
month
in
2012.
The
community
spouse
is
also
required
to
receive
additional
income
allowances
above
the minimum
rate
and
not
to
exceed
the maximum rate
for
excessive
utility
costs
or
excessive
costs
expended
to
maintain shelter.
In
most
states,
an
individual
needing
Medicaid
nursing
home
care
must
have assets
less
than
$2,000.
A
couple needing
Medicaid
nursing care
must
have assets
less
than
$3,000
in
most
states.
When one
member
of
a
couple
needing
care
in
a
nursing home
becomes
a
resident,
Medicaid
will
take
a
snapshot
of
the
coupleTs
combined
resources
at
that
point.
Resources
are
anything
that
can
be
converted
to
cash
to
pay
for
nursing home
care.
The
healthy
spouse
is
allowed
to
keep
up
to
half
of
these
resources
not
to
exceed
$113,640
(for
the
year 2012).
The
balance
of
the
resources
belong
to
the
nursing
home
spouse
and
must
be
spent
down
to
below
$2,000 before
Medicaid
will
start contributing
its
share
of
the
cost. There
is
no
requirement
that
the
nursing
home
Medicaid
recipient
must
spend
his
or
her share
of
the
resource
assets
on
the
nursing home.
The
money
can
be
spent
on
anything.
If
the
combined
resources are
less
than
$22,728
(for
the
year
2012)
the
healthy
spouse
keeps
it
all.
If
assets
are
between
$22,728
and
$222,280,
some
states
will
allow
the
community
spouse
to
keep
everything
up
to
$113,640.
These states
are called
lOO%
states.
Other
states,
called
50%
states,
are
less
generous
and
only
allow
the
community
spouse
to
keep
50°k
of
the
assets
up
to
$113,640.
Many
states
have
more
lenient
rules
pertaining to
the
amount
of
resources
that
can
be
retained
by
the
so-called
community
spouse
and
in
addition,
some
states exclude certain
types
of
community
spouse assets
as
counting towards
the
resource
test.
Updated
12/29/17
Page 29
Certain
assets
are
not
counted towards the
less
than
$2,000
asset
limit.
These
assets
are
exempt.
o
Personal
possessions,
such
as
clothing,
furniture,
and
jewelry
o
One
motor
vehicle
is
excluded,
regardless
of
value,
as
long
as
it
is
used
for
transportation
of
the
applicant
or
a
household
member. The
value
of
an
additional
automobile
may
be
excluded
if
needed
for
health
or
self-support
reasons.
(Check
your
state’s
rules.)
o
The
applicant’s principal
residence, provided
it
is
in
the
same
state
in
which
the
individual
is
applying
for
coverage
o
Prepaid
funeral
plans
and
a
small
amount
of
life
insurance
o
Assets
that
are
considered “inaccessible”
for
one
reason
or
another
In
some states
if
a
single
Medicaid
beneficiary
is
not
residing
in
the
personal residence
and
there
is
no
anticipation
that
person
can
return
to
his
or
her home,
the
State
may
require
that
the
home
be
sold
to
pay
for
Medicaid costs.
In
other
states,
the
home
can
be
left
vacant
in
anticipation
of
the
beneficiary
returning
whether
the
beneficiary
is
medically
capable
or
not.
In
some
states,
the
beneficiary
must
sign
an
intent
to
return
home
document
to
keep
the
home
from
being
sold
or
counting
as
an
asset
for
the
asset
test.
For
those states
that
have
adopted
the Deficit
Reduction
Act
of
2005,
a
home
worth
more
than
$525,000 ($786,000
in
some
states)
is
not
exempt
and
must
be
counted
as
an
asset
to
qualify
under
the
asset
test.
These
equity
limits
increase
in
response
to
inflation.
The
house
may
be
kept
with
no
equity
limit
if
the
Medicaid
applicant’s
spouse
or
another
dependent
relative
lives
there.
Although
mandatory
for
nursing
home residents,
states
are
not
required
to
offer
the
spousal
impoverishment
protections
discussed
above
to
home
and
community-based
service
waiver
program
participants.
Consequently,
a
substantial number
of
states
(19)
fail
to
offer the
spouses
of
waiver
participants the
full
level
of
income
and/or
asset
protection
afforded
the
spouses
of
nursing
home
residents.
Thirteen
states
protect
neither
the
income nor
assets
of
spouses
of
waiver participants,
and
an
additional
6
states
protect
the
assets
but not the
incomes
of
the community
spouses
of
waiver
participants
The
discussion
below
is
based
on
new rules
for
Medicaid
eligibility
that
were established
by
the
Deficit
Reduction
Act
of
2005.
This
act
was
incumbent
upon
all
states
to
adopt
the
new
rules.
Many
states
have
already
changed
legislation
and
regulations
to
incorporate the
new
rules
under
the
DRA,
but
a
number
of
states
have
not fully
implemented
these
rules
--
notably
California
and
Florida.
In
general,
in
those
states
that
have
not
adopted the
new
rules,
restrictions under
the
act
discussed
below
are
more liberal
towards transferring
assets
and
income
to
qualify
for
Medicaid.
Transferring
Cash
Assets
A
number
of
people
who
eventually
need
Medicaid
assistance
have
gifted
cash
or
cash
equivalent
assets
to
their
children
or
other
members
of
the
family either inadvertently
or
deliberately prior
to
applying
for
Medicaid,
Any
transfer
for
less
than
value,
whether
it
is
a
gift
or
at
a
reduced
purchase
price,
is
subject to
a
penalty
from
Medicaid
at
any
time
during
60
months
from the
date
of
the
gift.
The
penalty
is
calculated
by
dividing
the
Updated
12/29/17
Page 30
less-than-value
amount
of
the
transfer
by
the
average
monthly
Medicaid
nursing
home
cost
in
the
state.
Each
state
calculates
its
monthly
average
Medicaid
cost
at
least
yearly.
As
an
example,
suppose
John
transferred
s500,000 in
an
irrevocable
trust
to
his
children
4
years
ago.
He
received
nothing
in
return.
Now
John
needs
long
term
care
in
a
nursing home
and
applies
for
Medicaid.
Because
he
is
applying
for
Medicaid inside
of
the
60
month
look back
period
for
assessing
a
penalty,
he
will
not
qualify
for
Medicaid
assistance
until
the
penalty
has
been
satisfied.
John
has
two
options.
He
can
have
his
children reinstate the $500,000
back
into
his
name
and
do
away
with
the penalty
or
he
can
accept
the
penalty
and
have
the
children
pay
it
out of
the
trust.
The
penalty
is
calculated
by
dividing
the
$500,000
by
the
state
Medicaid
rate
which
is
55,000
a
month.
The
result
is
a
period
of
100
months or
approximately
8.3
years
where
John
must
pay
for
his
nursing
home cost
out
of
his
own
pocket
before
Medicaid
will
start
helping
him
cover
the
cost.
When
John
transferred the
assets
he
started
the
clock
ticking
on
what
is
called
the
look
back.’
This
is
a
period
of
60
months
or five
years
in
which
Medicaid
can
assess
the
penalty
if
a
transfer for
less
than
value
has
occurred.
After
the
look
back
has
been
met,
Medicaid
cannot
assess
a
penalty.
It
is
interesting to
note
in
this
example
that
had
John
waited
one
more
year,
he
would
not
have
incurred
a
penalty
of
8.3
years
from
Medicaid.
It
is
also
interesting to
note
that
the
penalty
is
longer
than
the
look
back.
If
John
were
anticipating
Medicaid
within
five
years,
he
would
simply
not
apply
for
Medicaid
until
he
had
met
5
years.
By
applying
for
Medicaid
before
this
time,
John
will
trigger
an
8.3-year
penalty.
John
simply
has
to
have
his
children
pay
the
remainder
of
the
5
years
out-of-pocket
and
then
apply
for
Medicaid.
This
is
a
much
cheaper
option.
Transferring
a
Personal
Residence
There
are
numerous
planning
strategies
to
transfer
a
personal residence
in
order to
avoid
a
transfer
for
less
than
value
or
to
avoid
Medicaid
recovery against
the
home.
Medicaid
planning
specialists
understand
the
rules
in
their
particular
states
for
doing
this.
Transfers of
the
home
may
also
be
made
under
the
following
conditions
without
Medicaid
penalty.
Here
are
those
exceptions.
transfer
to
the
applicants
spouse
o
transfer
to
a
child
who
is
under
age
21
or
who
is
blind
or
disabled
o
transfer
into
a
trust
for
the
sole
benefit
of
a
disabled
individual under
age
65
(even
if
the
trust
is
for
the
benefit
of
the
Medicaid
applicant, under
certain
circumstances)
o
transfer
to
a
sibling
who
has
lived
in
the
home
during
the
year
preceding
the
applicant’s
institutionalization
and
who
already
holds
an
equity
interest
in
the
home
°
transferred
to
a
“caretaker
child,’
who
is
defined
as
a
child
of
the
applicant
who
lived
in
the
house
for at
least
two
years
prior to
the
applicant’s
institutionalization
and
who
during
that
period
provided
care
that
allowed
the
applicant
to
avoid
a
nursing home
stay.
Medicaid Recovery
Federal Medicaid rules
require
states
to
attempt
to
recover
all
or
part
of
that
state’s
Medicaid costs
for
a
beneficiary
from the
beneficiary’s
estate.
Recovery
applies
to
Updated
12/29/17
Page 31
beneficiaries
age
55
and
older.
As
a
general
rule,
the
only
remaining
assets
would
be
the
principal residence
as
generally
all
other
assets
had
to
be
spent down.
But
certain
business
interests,
assets used
by
the
family
to
create
an
income
and
other
inaccessible
assets
could
also
be
excluded.
Even
though
many states
have
the
enabling
laws
to
recover
assets
held
in
any
arrangement
such
as
trusts,
assets
in
joint
tenancy
or
life
estates,
many
states
only
attempt
recovery
under
probate.
In many states,
the recovery program
is
underfunded
and
inefficient.
We
have
observed
that
many states
are
very
lax
in
their
ability to
recover
funds.
The
principal
means
of
recovery
is
putting
a
lien
against
the
home.
If
a
surviving
spouse
or
a
dependent
child
is
living
in
the
home,
recovery
will
not
take
place
until
the
house
is
sold
or
death occurs.
In
many
states,
no
lien
is
applied
if
the
surviving
spouse
is
living
in
the
home.
In
other
words,
the debt
under
recovery
is
forgiven.
Updated
12/29/17
Page 32
Important Information
and
Warnings
Regarding
Effective
Dates
and
“Intents
to
File”
(formerly
known
as
an
~Informal
Claim”)
This
article
was
written
to
help
senior
veterans
and
their
surviving
spouses
applying
for
VA
Pension
or
Death
Pension
understand
the
process
of
establishing
an
Effective
Date
with
the
Department
of
Veterans
Affairs
(VA).
This
article
also
explains
how
an
“Intent
to
File”
(formerly
know
as
an
Informal
Claim)
works
and
how
VA
may
grant
retroactive payment
if
certain criteria
are
met.
Furthermore,
this article
highlights
serious
issues
involving
the
filing
of
an”Intent
to
File’
before
a
claimant
(applying
for
pension
or
death pension)
has
met the
medical,
asset,
and
income
standards
set
by
VA.
EFFECTIVE
DATE
An
Effective
Date
is
typically
the
date
an
application
(or
original claim)
for
VA
Pension
or
Death
Pension
was
received
by
the Department
of
Veterans Affairs
(VA).
In
some
cases
(which
may
be
beneficial
to
the
claimant) there
are
exceptions
to
this
rule
which
can
allow
for
an
earlier
date.
(see 38
U.S.C.S.
§5110
and
38
C.F.R.
§3.400).
Generally, payments
for
a
VA
Claim
are
effective
from the
first
of
the
month
following
the
month
in
of
the
Effective
Date
(so long
as
an
award
is
given).
For
instance,
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qualify/ho
At?
year
off
sTh
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!/O/.€030
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cteuii
for
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epaw’e71
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the
ma
tiisof.ljoni
throuch
Shoternhel?
In
the
situation
above,
notice
that
the
lump
sum
retroactive
payment
did
not
include
the
month
of
March
when
the
veteran
made
application.
Although
the
effective
date
was
established
in
March,
the
VA
will
not
make
any
kind
of
payment
in
the
month
in
which
the
original
claim
was
received.
“INTENT
TO
FILE”
A
CLAIM
Before
applying
for
benefits
a
veteran
or
the
surviving
spouse
of
a
veteran
(in
either
case,
the
claimant)
may
wish
to
establish
an
Effective
Date
by
using
an
“Intent
to
File”
form
(VBA Form
21-0966).
“Intent
to
File,”
formerly
known
as
an
Informal
Claim,
can
be
sent
to
VA
even
though
a
claimant
is
not
yet
prepared
to
apply.
This
is
done to ‘lock-in
a
date’
while
the
claimant
is
gathering
supporting
evidence
to
include
in
their
application.
Supporting
evidence
can
take time
to gather
and
may
include
any
of
the
following:
o
Military
Records
•
Doctor’s
Examinations
and
other
Medical
Evidence
o
Marriage
and
Death
Certificates
•
Banks
Statements
•
Statements
from
Care
Providers
updated
12/29/17
Page 33
Using
an
“Intent
to
File”
to
establish
an
Effective
Date
before
the
claimant
has
sufficiently
prepared
his
or
her
application will
allow
the
claimant
to
receive
a
larger
lump
sum
retroactive payment
than
he
or
she
otherwise
would
have.
For
instance:
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In
the
situation
above,
had
the surviving
spouse
not
submitted
VBA
Form
21-0966,
her
Effective
Date
would
have
been
April
rather
than February
(she
would
have
missed
the
retroactive
payments
for
the
months
of
March
and
April).
Remember,
VA
will not
make
any
kind
of
payment
in
the
month
in
which
the
claim,
or
in
this
case
the
“Intent
to
File’,
was
received.
SPECIFICS
OF
AN
“INTENT
TO
FILE”
An
“Intent
to
File”
is
a
specific
declaration
of
intent
to
apply
for
benefits
from
the
VA.
An
“Intent
to
File”
can
be
submitted
in
one
of
the
following
three
ways
(38
CER
3.155):
ii)
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en7p/oyee
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[‘A
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the
claimant?
intent
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file
a
cialn~
~n
toe
cia~rnai7ts
recoros,
The
“Intent
to
File”
is
most
easily
accomplished
by
completing
VBA
Form
21-0966.
The
“Intent
to
File”
must:
ident/r3’
the
general
benefit
(Inc,,
compensation,
pensiOn),
but
need
not
identify
the
poecific
benefit
da~med
or
any medical
conthtlon(1)
on
170/foil
the
claim
it
based
The
Informal
Claim
must
also
list:
Updated
12/29/
17
Page 34
The
claimant’s
name
(if
other
than
the
Veteran)
2.
The
Veteran’s
name
3.
The
Veteran’s
social
security
#
4.
The
Veteran’s
birth date
Once
VA
receives
the
“intent
to
File”
(we
recommend
by
fax
AND
mail),
they
might
respond
to
the
claimant
by
sending
a
formal
application
(VBA
Form
21-527EZ
or
VBA
Form
21-534E7).
This
form
must
be
completed
within
one
year
from
the
date when
the
“Intent
to
File”
was
submitted.
If
the
claimant
does
not
submit
the
“Intent
to
File”
by
the
one-year
deadline,
the effective
date
established
by
the
“Intent
to
File”
will
no
longer
be
valid.
REMEMBER:
Always
keep
of
copy
of
anything
you send
to
VA
and
all
proof
of
any
transmition
or
mailing
(e.g.
fax
report
or
certified
mail).
SERIOUS
ITEMS
TO
BE
AWARE
OF
If
the
applicant
meets
the
medical
requirement
for
a
rating,
is
receiving
aid
and
attendance
services
and
can
demonstrate
having
paid
at
least one
month’s
worth
of
those
services
and
in
addition
meets
the
war
service
test,
and
meets
the
asset
test
and
the
income
test,
you
should
file
an
“Intent
to
File”
as
soon
as
possible.
This
will
establish
an
effective
date
with
VA.
If
you
do
not
meet
all
of
this,
ABSOLUTELY
DO
NOT
FILE
an
“Intent
to
File.”
Occasionally
(much
to
the
chagrin
of
the
claimant)
expectations regarding
an
Effective
Date are dashed
due
to
misinformation
or
a
lack
of understanding.
Below
are
a
few
examples
of
instances
where
a
claimant
was
expecting
retroactive
pay back
but
did
not
receive
what
was
expected.
EXAMPLE
1
(No Ongoing
unreimbursed
medical
expenses
(UMEs)
present
at
the time
the
“Intent
to
File”
was
submitted):
An
53
i/B3i
Q/Q•
5//?
/
VEieIei7
S
/7(7755
/770/
717?!
1!
~ncoine
is
cC
000.
He
lives
at
i~an~e
af
clue
to
his
poor
./7aalth
ne
real
ures
he/c?
v’/th
bath/np.
L7i?055/flQ.
wa/~c~na
arOtfl7C
/7/5
home,
and
chad/nc
/7//nse/.f
He
scrbim’ts
V&4
Form
21
-0966
to
VA
Ia
January
then
appere~
for
Feresisn
is
sipi/t
A
.isw
aere•~s
b.erZins
he
con?plecad
/u~
appficatiorr
,he
/7/nod
S
i7onle
care
camper/vIa
cr/cS
and
feed
i/Ho
healthy
meis/
heip
hIm
Dali/c.
chess.
and
move
a~vuryd
lyle
haccce,
Ft/i
I/IS
service
he
nays
c/i,
403004070/7th.
He
ihciudes
this
cost
an
his
app//cat/cu.
In
240/
[‘A
ai;
t•~ams
him
the
bench
t
but
dares
nat
grant
a
re/Inactive
nayment
far
me
n7c’nths
of
February
and
Mamrh
bacause,
durIng
tnat
0177/f.
the
veteran
b
incmynle
exceeded
the
income
i/nuts
(I
a
he
did
not
have
any
an
onoa~nc
care
cc5~,.
to
reducn
/7/5
inca/ne
51
/15
7flP17
f/v
EXAMPLE
2:
(Bad
/
Incomplete
Information):
An B5
year
old
si/ale
veteran
is
manna
i/to
an
assisted
I/n/p
fac/l’ty
and
learns
that
he
is
e14jTh/e
fcc
Si,
79r7’/nont/i
thivuph
[/4
Pension
with
Aid
and Atiandanca
His
saw//s
have venished
and
h/s
income
m•v/ll
not
adequabafy
cover the
care
casal
t//?fertlinate40
Updated
12/29/17
Page 35
c~
~
~7C~
~
CI[ftF~t.
75
flu/C
tw
tik•:.~
•/aCdtfl
Ll.5/V~
arC
St/tI
rfll
/3/It/V
/5
/fl9/5
3/.(t
/3/7/I
F.fl71
/7/5
3/IS/C
fl3r~
fl75~
rfl,~/7flhc
/7~t
1fl1;~L/1/)
/7?3/r/~
A/i
with
in
le
53/73
:‘77~7i2//
/~:)‘CV0~~n
/770/IS
nV//I
the
/hlflht/z,
fl/S//Is
4):;
/72/F/i
thuds
en
Cc/cot
to
F//c
em/i
.sar~os
:Vi~1/
c/a/ni
to
the
L7i~
753//n /770/7375
F:~~
el/a:
/3/
27
to
,
3
C C
,ch
CV~
/7/I3
/7C
070,7th
/1/77757
5/10?
,211V/77e/7//
15
/707
/537/3:
~/7Q~gfl
70
oecy
the
~‘l~/l
/7770/
/70V./..
7//Lie
r,
~/5
~Th
t733/S
13
2,
23’
~‘
75
—
Cu
~
c
/777/77
Iii
IT
thc:
:?/7.i.F7/.::
ore
7770/7th //7
Fi/h./dl
tile
c/1i~tri
~75r
‘Jhteilt
to
5th
/17
rece/Iec/
/7/3’
00/ltd
/F’eI47P
77303
3
tIe/ten
0/70/ce
~eqc/70hx~i
7/71’
/03.17,
On
rare occasions,
establishing
an
Effective
Date
can
be
detrimental
to
the
success
of
the
application.
Below
is
an
example
where
a
claimant
filed
an
“Intent
to
File
and
was
disqualified
because
of
it.
EXAMPLE
3
(Too
Many
Assets):
A/i
84
~air
old
sun..
~17~717(7
s~2n’n/se
ci
a
veteian
lh’es
07
/777
assisted
i/v//ia
fan//fr
and
lt’a/lts
iv
cop/v
i•c/)r
Di:eth /23n5/Q/7
F4’/07
the
,//id
3/76’
Atte.t~o75noe
Ai/oitaiice,
She
has
(cOol
000
hI
sc-cs
CV
soc
c
cc,
‘rte-
Sic
,cts/,ecoe’
~
/075
r5
c//ta
/he
/
6’
077•l/7Q
.month
the
/i/7/71775>J/
(i//CS
50/773
es/etc
p/e/7ru/7q
iv
/7(34/7
/7/3/7
meet
the
asset
4n~:tc
set
rbnth
fit:.
i.’A.
/lQ/i7~’
/17’13[.’Q//I/77/e
ta/st
7~7fl~’
7/s
ChIle.
:777Q’ Li~:70/7
ccmp/etiori,
si7e
fl/es
her
avpi/cat’bn.
filth/ic
processing
her
appi/caflon.
LA
learns
that
,
5000757
“
53~e~
V
IT
/7
Ci
IT’?
7l’t
o’nc~
‘0070
POlar
1’iC
‘ritert
L
C/3/
~
5~’L77’/’tCn
/5,/IC
tots
“thy’
rilO
C” CE/i/cs
net
o/a’n7
:ased
C/i
~E
thot
‘/“7
d~e
73~7
(3/7000/7
355535
1/7
rjer
~
tü
0/377’
fOr her
0/577
care
at
the
7/7’
5/78
/73d
esiah/’/shed en
el//sc/h
e
adte.
Updated
12/29/17
Page 36
WAIVER
AND ACKNOWLEDGMENT
FOR
SERVICES
BY
THE UPPER
PIONEER
VALLEY VETERANS’
SERVICES
DISTRICT
I,
,
state
that
I
have
requested
information,
advice
and/or
assistance
(“services”)
from the
Upper
Pioneer Valley
Veterans’
Services
District,
its
staff,
employees
and/or
affiliates,
regarding
—
from
the
U.S.
Department
of
Veterans
Affairs
(Ttthe
federal
benefit”).
By
signing
below,
I
acknowledge
that
I
want
to proceed
with the
application
process
for
the
federal
benefit
by
using
the
services
provided
by
the
Upper
Pioneer Valley
Veterans’
Services,
its
staff,
employees
and/or
affiliates.
I
also
understand
and
acknowledge
that
the
staffimember(s)
and/or employee(s}from
the
Upper
Pioneer
Valley
Veterans’
Services
District,
who
are
providing
me
with
services related
to
the
application
process
for
the
federal
benefit,
:s/are
NOT~employedby the
IJ.S.
Department
of
Veterans
Affairs. -
-
I
also
affirm
that
I
have
not
paid
the
Upper Pioneer Valley
Veterans’
Services
District,
its
staff,
employees
and/or
affiliates
for
any
services related
to the
federal
benefit.
I
give
permission
to
the
staff
and/or
employees
of
the
Upper
Pioneer
Valley
Veterans~
Services
District
to
assist
in
the preparation
of
my
application
for
the
federal
benefit.
I
further
acknowledge
that I
am
aware
that
this
process
may have
an
impact
on
any future
application
that
I
file
for
Medicaid.
I
further
acknowledge
and
accept
that
the
Upper
Pioneer
Valley
Veterans’
Services
District,
its
staff,
employees
and/or
affiliates
cannot guarantee
the
federal
benefit
will
be
received.
I
realize
and
am
aware
that
there
are
income
and asset
qualifications,
and
that
the~e
may
be
tax
consequences related
to
my
application
for
the federal
benefit.
I
understand
that
I
may
consult
with
my
own
attorney,
accountant,
or
other
professionals
in
regard
to
the
application
for
the
federal
benefit
at
any
time
during
the
application
process
for
the
federal
benefit.
By
signing
below,
I
hereby
agree
to
hold
harmless
and
release
from
all
liability
the
Upper
Pioneer
Valley
Veterans’
Services
District,
its
staff,
employees
and/or
affiliates
related
to
any
services
that
they
have
provided
to
me
and
the
application
process
for
the
federal benefit.
Page 37
I
also
agree
to notify
and
inform
the
Upper Pioneer Valley
Veterans’
Service
District
of
any
correspondence,
phone
calls,
or
requests
for
additional
information
from
the
U.S.
Department
of
Veterans
Affairs
that
are
received
by
me
or
are
related
to
the
services
provided
by
the
Upper
Pioneer Valley
Veterans’
Services
District,
its
staff,
employees
and/or
affiliates
and
the
federal
benefit
application
process.
Signature
of
Individual
Receiving
Services
Date
F:\ALL
VA
folders\HoId
Harmless
Agreement-A4ocx
Page 38
You will need the Veteran’s DD-214 and, if applicable, copies of the marriage license/divorce
decrees and the Veteran’s death certificate. If the applicant is living in an assisted living
facility, a letter is required from that facility stating when entered & how much they pay.
Please bring completed application packet back into our office for
review and submission to the US Department of Veterans Affairs
Upper Pioneer Valley Veterans’ Services
1-413-772-1571
Page 39
4A.
VETERAN’S
SOCIAL SECURITY
NUMBER
45.
CLAIMANTS
SOCIALSECURIrY
NUMBER
5.
CLAIM NUMBER
6.
DATEOFEXAMINATION
7.
HOMEAODRESS
BA.
IS
CLAIMANT
HOSPITALIZED?
SB.
DATE
AOMIVrED
9.
NAME
AND
ADDRESS
OF
HOSPITAL
~
YES
~
NO
(U’Y~’.t”conp/c(e/to,rsSB
ag,l~)
NOTE:
EXAMINER
PLEASE
READ
CAREFULLY
The
purpose
of
this
examination
is
to mcord
manifestations
and
findings
pertinent
to
the
question
oFwhether
the
claimant
is
housebound
(confined
to
the
home
or
inmediale
preniises)
orin
need
of
the
regular
aid
and
attendance
of
another
person.
The
report should
be
in
sufficient
delail
for
tIle
VA
decision
makers
to
delernlinc
he
extent
that
disease
or
injuty
produces
physical or
mental
impairment,
Ihat
loss
of
coordination orenfeeblement
affeels
the
ability;
to
dress
and
undress;
to
feed
himThersel~
ID
attend
to
Ilte wants
of
nature;
or
keep
hitn/herseifordinarily
clean
and
presentable.
Findings
should
be
recorded
to
show
whether
the
claimant
is
blind
or
bedridden.
Whether
llie
claimant
seeks
housebound
or
aid
and
ottendanee
benefils,
Ilte
report
should
reflect
how
well
he/she
ambulates. where
he/she goes,
and
what
he/she
is
able
to
do
during
a
typical
day.
10.
COMPLETE
DIAGNOSIS
/DM~nosIs.wcds
toe,jieztu
to
the/tad
of
ossistonce
described
in
questions
20
throng/i
34
hA.
AGE
h1&
SEX
12.
WEIGHT
13.
HEIGHT
ACTUAL:
LBS.
ESTiMATED:
LB&
FEET;
INCHES:
14.
NUTRITION
15.
GAIT
16.
BLOOD
PRESSURE
17.
PULSE RATE
10.
RESPIRATORY
RATE
j
1S~
WrIAT
DISABILITIES
RESTRICT
THE
USTED
ACTIVITIESIFUNCtONS?
20.
IF
THE
CLAIMANTIS
CONFINEDTO
BED,
INDICATE
THE NUMBER
OF
HOURS
IN
BED
Fcom9PMI09AM: From9AMto9PM:
21.
IS
THE
CLAIMANTABLE
TO
FEED
HIMJHERSELF?
(ff’Wc,”pror;treexpThnonoi~
EYES
END
22.
5
CLAIMANT
ABLE
TO
PREPARE
O~4
MEALS?
(ffWo.epro.ide
cvp/ornatioii)
EVES
ENO
23.
DOESTHE
CLAIMANT
NEED
ASSISTANCE
IN
BATHINGAND
TENDING
TO
OTHER
HYGIENE
NEEDS?
(U’}twpro’vdeesp/onoltoo)
EYES
~NO
24A.
IS
THE
CLAIMANT
LEGALLY BLIND?
(If
7es.’prorit/u
nrp/auanoz~
245.
CORRECTED VISION
LEFT
EYE
RIGHT
EYE
EYES
END
25. DOES
THE CLAIMANT
REQUIRE NURSING
HOME
CARE?
(If
7cr.e
provide
espianotionj
EYES
ENO
26.
DOES
TIlE
CLAIMANT REQUIRE MEDICATION
MANAGEMENT?
W
“Yes.”proritk
nvplotrotlaoj
flYES
ENO
27.
DOES
THE CLAIMANT
HAVE
THEASILITY
TO
MANAGE
HISIHER OWN
FINANCIAL AFFAIRS?
f/fWo.’
provide
s-cplonniion)
EYES
ENO
Department
of
Veterans
Affairs
1,
FIRST
NAME-
MIDDLE
NAME-LAST
NAMC
LW
V
0MB
Control
No.
2900-0721
Respondait
Bnrdcn:
30
minutes
Expiration
Dow:
5-31.2018
EXAMINATION
FOR
HOUSE8OUND
STATUS
OR
PERMANENT
NEED FOR
REGULAR
AID
AND ATTENDANCE
FIRST
NAME
-
MIDDLE
NAME
-
LAST
NAME
OF CLAIMANT
3.
RELATIONSHIF
OF
CLAIMANT
TO
VETERAN
VA
FORM
MAY2015
21-2680
SUPERSEDES
VA
FORM
21-2680,
JUN
2008,
WHICH
WILL
NOT
BE
USED.
Page 40
28.
POSTURE
AND
GENERAL
APPEARANCE
IAI,.rk
C?
.tepOflflr siw,’,
of
paper
~fadhi?r.snaLipace
u
.wdrdi
29.
DESCRIBE
RESTRICTIONS
OF
EACH
UPPER
EXTREMITY
WIN
PARTICULAR
REFERENCE
TO
GRIP,
FINE
MOVEMENTS.
AND
ABILITY
TO
FEED
HIM(HERSELF.
TO BUTTON
CLOTHING,
SHAVEANDAUENDTOTHE
NEEDS
OF
NATURE
fA
z,ackrtseparrne
sheet
~f
paj,cr
,(adrhim.ral
af
C,’
b
na’Jrd)
30.
DESCRIBE RESTRICTIONS
OF
EACH
LOWER
EXTREMITY
WTH
PARTICULAR
REFERENCE
TO THE
EXTENT
OF LIMITATION
OF
MOTION.
ATROPHY.
AND
CONTRACTURESOR
OTHER
INTERFERENCE.
IF
INDICATED,
COMMENT
SPECIFICALLY
ON
WEIGHT
BEARING.
BALANCE
AND
PROPULSION
OF
EACH
LOWER
EXTREMITY.
31.
DESCRIBE
RESTRICTION
OF
THE SPINE.
TRUNKAND
NECK
32
SET
FORTH
ALL
OTHER
PATHOLOGY
INCLUDING
THE
LOSS
OF
BOWEL
OR
BLADDER
CONTROLOR
THE
EFFECTS
OFADVANCING
AGE.
SUCH
AS
DIZZINESS.
LOSS OF
MEMORY
OR POOR
BALANCE,
THAT
AFFECTS CLAIMANT’S
ABILITY
TO
PERFORM
SELF-CARE,
AMBULATE
OR
TRAVEL
BEYOND
THE
PREMISES
OF
THE HOME.
OR, IF
HOSPITALIZED.
BEYOND
THEWARD
OR
CLINICAL
AREA. DESCRIBE WHERE
THE
CLAIMANT
GOES AND
WHAT
HE
OR
SHE
DOES
DURING
ATYPICAL
DAY.
33.
DESCRIBE
HOW
OFTEN PER DAY
OR
WEEK
AND
UNDER WHAT
CIRCUMSTANCES
THE
CLAIMANT
IS
ABLE
TO
LEAVE
THE
HOME
OR
IMMEDIATE PREMISES
34.
ARE
AIDS
SUCH
AS
CANES,
BRACES, CRUTCHES,
DR THE
ASSISTANCE
OF
ANOThER
PERSON REQUIRED
FOR
LOCOMOTION?
~J[s’rt
specie- ant)
,faccnhe
“terms
y’ekv?ance
Macam
ha
tnnefed.:,a
at
Ii.’,n
32
ahut~’)
YES
(I,f7ES,”gi.’cthrranru)
((‘hack
OTHER
NO
d~sp)irabk’
hux
arspecsfr
Mama
a,)
fl
I
BLOCK
S
or
B
BLOCKS Q
I
MILE
a~,wcsfr.timwic4
ISA.
PRINTED
NAME
OF
EXAMINING
PHYSICIAN
35B.
SIGNATURE
AND TITLE
OF
EXAMINING PHYSICIAN
35C.
DATE
SIGNED
36A.
NAME
AND
ADDRESS
OF
MEDICAL FACILITY
36B.
TELEPHONE
NUMBER
OF
MEDICAL
FACILITY
(jar)
ideA
ret,
C’adej
PRnc4CY
ACT
NOTICE:
The
VA
will
not
disclose
information
collected
on
this
fern,
to
any source
other
dm11
vhat
has
been
authorized
under
the
Privacy
Act
or
974
or
Title
33,
code
Di
Federal
Regtilations
1,576
for
routine
tisos
(i.e..
civil
or
criminal
law
enforcement,
congressional
comlnunicanons,
epidetaiological or
research
studies,
the
cDIIeetiDn
of
money
owed
to
the
United
States,
lItigatIon
In
tt’llIth
the
United
States
isa
party
or
liar
an
ititeI~St.
the
adntinistratiDn
of
VA
Pt~gtmtrn
and
delivery
of
VA
benefits,
verification
of
identity
and
slattts.
and
personnel
administration)
as
identified
iii
the
VA
system
of
records.
58VA2
1/22/23,
Compensation.
Pension,
Education
end
Vocational
Rehabilitation
Records
-
VA,
and
published
in
the
Federal
Register.
Your
obligation
to
respond
is
required
to
obtain
or
rettin
benefits.
Oiving
usyourSocial
Security
Numbor(SSN)account
information
is
mandatory.
Applicants
are
requiredioprovtdetheirSSN
underlitle
38,
U.S.C.
57D1(cXl).
The
VA
will
not
deny
an
ndtvtdual
benefits
lbr
refusing
to
provide
his
or
her SSN
unless
die
disclosure
is
required by
a
Federal
Stawte
oflaw
in
cITeet
prior
to
Jwitow
I,
975.
and
still
in
effect,
The
requested
infnnnitlion
is
considered
relevant
aitd necessary
to
deiern,ine
inaxitnunt
benefits
provided
under
the
law.
The
responses
you
submit
are
eonsidcred
confidential
(38
U.S.C. 5701).
Informalion
that
you
furnish
iutq
be
tililized
in
computer
malelting
programs
with
other
Federal
or
state
agencies
for
the
purpose
ofdetennining
your
eligibiliry
to
receive
VA
benefits,
as
~vell
as
to
collect
any
amount owed
to
the
United
States
by
virtue
ol’yoitr
participation
in
any
benefit
program
administered
by
the
Department
ofVtterens
Affairs.
RESPONDENT
BURDEN:
We
need
this
information
todetennine
youreligibilityl’oraid
and
attendance
orhouscbound
benefits.
TitleJ8,
United StatesCode
1521
(d)
and
(e),
II
lS(fl(e),
1311(c)ond
(d).
1315(h),
1122.
1541(d)le),
and
1502(b)
and
(e~
allows
tis
to
ask
for
this
information.
Weestimale
that
you
will
need
an
average
of
3D
minutes
to
review
the
inslriietions,
find
the
infortiation,
and
complete
this
form.
VA
cannot
conductor
sponsora collection
of
information
unless
a
valid
0MB
ronfrol
number
is
displayed.
You
ore
not
required
to respond to
a
collection
of
information
if
tlus
number
is
not displayed.
Valid
0MB
control
numbers
can
be
loealed
on
the
0MB
interact
pate
at
iaflp://w~nv.rreiin~.’.nvfnnhlir/rltmfl’htAMain.
If
destred,
you
can
call
1.300-327’
000
to
get
ittfornsation
on
where
to
send
comments
or
suogestions
about
ibis
fonn.
VA
FORM
21-2eaD,
MAY
2015
Page 41
Department
of
Veterans
Affairs
0MB
Control
No.2900-0321
Respondent
Burden:
5
minutes
APPOINTMENT
OF
VETERANS
SERVICE
bäGANIzATJON
AS
CLAIMANT’S
REPRESENTATIVE
NOTE
—
If
you
would
prefer
to
have an
individual
assist
you
wit!,
your
claim,
you
may
use
VA
Form
2l-22n,
“Appointment
oflndividual
as
Claimant’s
Representalive.”
VA
Forms
are
available
at
~n~’w.va.~seThVivnfor,nc.
IMPORTANT
-
PLEASE
READ
THE
PRIVACY ACT
AND
RESPONDENT
BURDEN
ON
REVERSE
BEFORE
COMPLETING THE
FORM.
1,
LAST-FIRST-MIDDLE
NAME
OF
VEtERAN
2.
VA
FILE
NUMBER
(biclirdeprefl.~)
3k
NAME
OF
SERVICE
ORGANIZATION RECOGNIZED
BY
THE
DEPARTMENT
OF
VETERANS AFFAIRS
(See
list
on reverse side
before
selecting
orgnrn;atiort)
MASSACHUSETTS DEPARTMENT OF
VETERANS’
SERVICES
SB.
NAME
AND
JOB
TITLE
OF
OFFICIAL
REPRESENTATIVE ACTING
ON
BEHALF
OF
THE
ORGANIZATION
NAMED
IN
ITEM 3A
(Ylds
is
on
appointment
of
the
entire
organization
and
does
nor
indicate
the
designation
of
only
this
specific
indivithtal
to
act
on
be
half
of
the
organization)
SC.
E-MAIL
ADDRESS
OF
THE ORGANIZATION
NAMED
IN
ITEM
3A
DVSVACONTACTS@MASSMAIL.5TATE,MA.rJS
INSTRUCTIONS-TYPE
OR
PRINT
ALL
ENTRIES
4.
SOCIAL SECURITY
NUMBER (OR
SERVICE NUMBER.
IF
NO
SSN)
5.
INSURANCE
NUMBER(S)
(Jnchidt
letter
prefis)
6.
NAME
OF
CLAIMANT
(if
oAr,’
than
rcttranj
7.
RELATIONSHIP
TO
VETERAN
8.
ADDRESS
OF
CLAIMANT
Qlo.
and
street
or
rival
‘-ante,
city
or
P.O..
Stow
and
ZIP
Code)
9.
CLAIMANTS
TELEPHONE
NUMBERS
t’iaclnde
Area
Code)
A.
DAYTIME
B.
EVENING
10.
E-MAIL
ADDRESS
(if
apphcobte)
11.
DATE
OF
THIS
APPOINTMENT
12.
AUTHORIZATION
FOR
REPRESENTATIVE’S
ACCESS
TO RECORDS
PROTECTED
BY
SECTION
7332,
TITLE
38,
U.S.C.
By
checking
the
box
below!
atttltorize
VA
to
disclose
to
the
service organization
named on
this
appoinlment
form any
records
that
may
be
in
my
file
relating
to
treatment
for
drug
abuse,
alcoholism
or
alcohol
abuse.
intèclion
with
the
human
immunodeficiency
virus
(HIV),
or
sickle
cell
anemia.
I
aulhorize
the
VA
facility
having
custody
ofmy
VA
claimant
records
to
disclose
to
the
service
organization
named in
Item
3A
all
treatment
records
relating
to
drug
abtise,
alcoholism
or
alcohol
abuse,
infection
with
llte
human
imnaunodeficiency
virus
(HIV),
or
sickle
cell
anemia.
Redisclosure
of
these
records
by
fly
service
organization
representative,
other
than
to
VA
or
the
Court
of
Appeals
for
Veterans
Claims,
is
not
authorized
without
ny
farther
wrilten
consent.
This
authorization
will
remain
in
effect
until
the
earlier
of
the
following
events:
(1)1
revoke
this
authorization
by
tiling
a
written
revocation
with
VA:
or
(2)1
revoke
the
appointment
of
the
service
organization
named
above,
either
by
explicit
revocation
or
the
appointment
ofanother
representative.
13.
LIMITATION
OF
CONSENT
—
t
authorize
disclosure
ofrecords
relaled
to
treatment
for all
eondilions
listed
in
tlcm
12
except:
D
DRUG
ABUSE INFECTION
WITH
THE
HUMAN
IMMUNODEFICIENCY
VIRUS
(HIV)
ALCOHOLISM
OR
ALCOHOL
ABUSE
SICKLE CELL
ANEMIA
14.
AUTHORIZATION
TO
CHANGE CLAIMANT’S
ADDRESS
-
By
checking
the
box
below,
I
authorize
the
organization
named
in
[tern
3A
to
act
on
my
behalf
to
change
my
address
in
my
VA
records.
I
authorize
any
official
representative
of
the
organization
named in
Item
3A
to
act
on
my
behalf
to
change
my
address in
my
VA
records.
This
authorization
does
not
extend to
any
other
organization
without
my
further written
consent.
This
authorization
will
remain
in
effect until
the
earlier
of
the
following
events;
(1)1
file
a
written
revocation
with
VA:
or
(2)1
appoint another rcprcsentative,
or
(3)
t
have
been
determined
unable
to
manage
my financial affairs
and
the
individual
or
organization
named in
ttene
3A
is
not
my
appointed
fiduciary.
I,
the
claimant
named
in
Items
I
orG,
hereby
appoint
the
service
organization
named in
Item
3A
as
my
representative
to prepare,
present
and
proseeate
my
claim(s)
for
any
and
all benefits
from
the
Department
of
Veterans
Affairs
(VA)
based on
the
aervice
ofthe
veteran
named
in
Item
1.1
authorize
VA
to
release
any
and
all
ofmy
records, to
include disclosure
ofmy
Federal
tax
information
(other
than
as
provided
in
teems
12
and
13),
to
my
appointed
service
organization.
I
understand
that my
appointed
representative
will
not
charge any
fee
or
compensation
for
service
rendered
pursuant
to
this
appointment.
I
understand
that
the
service
organization t
have
appointed
as
my representative
may
revoke
this
appointment
at
any
time,
sttbjeet
to
38
CPA
20.608.
Additionally.
in
sonic
cases
a
veteran~r
income
is
dereloped
because
a
match
with
die
Internal
Revenue
Senice
necessitated
laconic
verification.
in
such
cases.
llte
assignment
of
the
service
organization
as
the
vete,vn~s
representative
is
validfor
on~t’fiveyearsfron;
the
date
the
claimant
signs
elusforluforpeaioosrs restricted
to
the
verification
snatch.
Signed
and
accepted
subject
to
the
foregoing
conditions.
THIS
POWER
OF
ATTORNEY
DOES
NOT
REQUIRE
EXECUTION
BEFORE
A
NOTARY PUBLIC
15.
SIGNATURE
OF
VETERAN
OR
CLAIMANT
(DnNotPrtnt)
16.
DATE SIGNED
17.
SIGNATURE
OF
VETERANS
SERVICE
ORGANIZATION REPRESENTATIVE
NAMED
IN
ITEM
3B (Do
Not
Print.?
18.
DATE
SIGNED
COPY OF
VA
FORM
21.22
SENTTO:
DATE SENT
ACKNOWI.EDGED
REVOKED (Reason
acid
doit)
L
VR&E
FILES
~
EDU FILE
(Date)
ONLY
D
LG
FILE
INSURANCE
FILE
NOTE:
As
long
as
this
appointment
is
in
effect,
the
organization
named
herein
will
be
recognized
as
the
sole
representative
for
preparation,
presentation
and
proseetttion
ofyour
claim
before
the
Depanmcnt
of
Veterans
Affairs
in
connection
with your
claim or any
poreton
thercot
JA
FORM
21-22
SUPERSEDES VA
FORM 21-22,
JUN
2014,
El
OCT 2014
WHICH
WILL
NOT
SE
USED.
Page 42
Department
of
Veterans
Affairs
APPLICATIONFOR
PENSION
0MB
Control
No.
2900-0002
Respondent
Burden:
25
minutes
Expiration
Dale:
413012019
VA
DATE
STAMP
(DO
NOT
WRITE
IN
THIS
SPACE)
IMPORTANT: Please
read
the
Privacy
Act
and Respondent
Burden
on
page
8
before
completing
the
form.
SECTION
I:
VETERANS
PERSONAL
INFORMATION
(MUST
COMPLETE)
1.
VETERAN’S
NAME
(Last
first,
middle)
2.
SOCIAL SECURITY
NUMBER
3.
DATE
OF
BIRTN
(MM,DD.YYYY)
4.
SEX 5.
HAVE
YOU
EVER
FILED
A
CLAIM
WITH
VA?
6.
VA
FILE
NUMBER
fl
MALE FEMALE
~J
YES
NO
(It
‘Yes,
provide
your
file
number
in
Item
6)
-
7A.
MAILING
ADDRESS
78.
TELEPHONE
NUMBERS
(Include
Area
Coda)
DAYTIME
Street
address,
rural
route,
or P.O.
Box
Apt.
number
(
EVENING
(
)
City
State
ZIP
Code
Country
CELL
PHONE
SA.
PREFERRED
E-MAIL
ADDRESS
(if
appflcable)
SB.
ALTERNATE
E-MAIL
ADDRESS
(If
applicable)
9.
WHAT
DISABILITY(IES)
PREVENTS
YOU
FROM
WORKING?
A.
DISABILITY(IES)
I
B.
DATE
DISABILITY(IES) BEGAN
.
10.
LIST
ANY
VA
MEDICAL CENTERS
WHERE
YOU
RECEIVED
TREATMENT
FOR
YOUR
CLAIMED
DISABILrfl’QES)
AND
PROVIDE
TREATMENT
DATES
A.
NAME
AND
LOCATION
OF
VA
MEDICAL CENTER
B.
DATE(S)
OF
TREATMENT
SECTION
II:
VETERAN’S
SERVICE
INFORMATION
(MUST
COMPLETE)
hA.
DID
YOU
SERVE
UNDER
ANOTHER NAME?
1
lB.
PLEASE
LIST THE
OTHER
NAME(S)
YOU
SERVED
UNDER
~
YES
(If’Yes.’
complete
tlem 118)
fl
NO
(If
‘No,’
skip
to
Item
h2A)
12A.
I
ENTERED
ACmE
SERVICE
ON
(MM.DD,Y’rYY)
128.
BRANCH
OF
SERVICE
12C.
RELEASE
DATE
ORANTICIPATED
DATE
OF
RELEASE
FROM
ACTIVE
SERVICE
12D.
DID
YOU SERVE
IN
A
COMBAT
ZONE
SINCE
9-11-2001?
12E.
PLACE
OF
LAST
ORANTICIPATED
SEPARATION
~
YES
NO
13A.
ARE YOU
CURRENTLYACTIVATED
TO
FEDERALACTIVE
DUTY
UNDER
THE
13B.
DATE
OF ACTIVATION
(MM,DD,YY”YY)
AUTHORITY
OF
TITLE
10,
U.S.C. (National
Guard)?
~
YES
El
NO
(If”Yes,”
provide
date
of
activation
in
Item
138)
14A.
WHAT
IS
THE
NAME
AND
ADDRESS OF
YOUR RESERVE/NATIONAL GUARD
UNIT?
149.
WHAT
IS
THE
TELEPHONE
NUMBER
OF
YOUR
CURRENT
UNIT?
(Include
Area
Code)
(
)
ISA.
HAVE
YOU
EVER
BEEN
A
PRISONER
OF
WAR?
158.
DATES
OF
CONFINEMENT
ON
(MM.DD,Y’yYY)
~
YES
El
NO
(If
‘Yes,’
complete
Item
1
SB)
III
‘No7
skip
to
Item
1
GA)
From:
To:
16A.
DID
YOU
RECEIVE
ANYTYPE
OF
SEPARATION/SEVERANCE
1GB.
LIST
AMOUNT
(If
known)
16C,
LISTTYPE
(It
known)
RETIRED
PAY?
fl
YES
~
NO
(If
“Yes,”
complete
Items
165
and
16C)
$
SECTION
III:
VETERAN’S
WORK
HISTORY
(MUST
COMPLETE)
NOTE:
in
the
table
be/ow,
tell
us
about
all
of
yourenip/oyment,
including
se/f-employment,
for
one
year
before
you
became
disabled
to
the
present.
17A.
WHAT
WAS
THE NAME
AND
ADDRESS
OF
178.
WHATWAS
17C.
WHEN
DID
17D.
WHEN
DID
DAYSWERE
LOST
ITF.WHAt
WERE
YOUR
EMPLOYER?
YOUR
JOB
TITLE?
YOUR
JOB
BEGIN?
YOUR
JOB END?
DUE
TO
DISABILITY?
ANNUAL
EARNINGS?
S
S
VA FORM
21P-527EZ
APR
2D16
SUPERSEDES
VA
FORM
21-527E2.
JUN
2014,
WHICH WILL NOT
BE
USEa
Page
5
Page 43
SECTION
IV:
MARITAL
STATUS
(MUST
COMPLETE)
lEA,
WHAT
IS
YOUR
MARITAl,
STATUS?
(Check
erie)
fl
MARRIED DIVORCED
WIDOWED
NEVER
MARRIED
(Skip
1~
Section
VI if
never
married)
TELL
US
ABOUT
YOUR
MARRIAGE(PREVIOUS MARRIAGES
lOB.
HOW
MANY
TIMES
HAVE
YOU
BEEN
NARRIED
(including current
marriage)?
19D.
HOW
MARRL4G!
WE.
DATE
(month,
day,
ISA.
DATE
(month,
day,
year)
AND
PLACE
OF
198.
TO
WHOM
19C.
TYPE
OF
MARRIAGE
1
TERMINATED
year) AND
PLACE
MARRIED
(ceremonial,
common-law,
I
MARRIAGE
(city/slate
or
country)
(first
middle,
last
name)
proxy.
tribal,
or
other)
(death,
dIvorce,
marriage
has
not MARRIAGE
TERMINATED
been
terminated)
(city/stale
or
country)
191’.
IF
YOU
INDICATED
“OTHER’
AS TYPE
OF
MARRIAGE
IN
ITEM
19C,
PLEASE
EXPLAIN:
SECTION
V:
CURRENT
MARITAL
INFORMATION
(COMPLETE
ONLY
IF
YOU
ARE
CURRENTLY
MARRIED)
Note
-
Skip
to
Section
VIII
not
currently married.
TELL
US
ABOUT
YOUR SPOUSE’S
MARRIAGE’PREVIOUS
MARRIAGES
20.
HOW
MANY
TIMES
HAS
YOUR
SPOUSE BEEN MARRIED
(including
current
marriage)?
21D,
HOW
MARRIAGE
21!.
DATE
(month,
day,
21A.
DATE
(month,
day,
year) AND PLACE
OF
218.
TO
WHOM
21C.
TYPE
OF
MARRIAGE
TERMINATED
year)
N~D
PLACE
MARRIED
(ceremonial,
common-law,
MARRIAGE
(city/state
or
country) (first,
mIddle, last
name)
proxy,
tribal,
or
other) (dealh.
divorce.
marrIage
has
not
MARRIAGE
TERMINATED
been
terminated)
(city/slate
or
country)
2W.
IF
YOU
INDICATED “OTHER’
AS
TYPE
OF
MARRIAGE
IN
ITEM
210,
PLEASE
EXPLAIN:
22A.
WHAT
IS
YOUR
SPOUSES
DATE
OF
I
228.
WHAT
IS
YOUR
SPOUSE’S
220.
IS
YOUR SPOUSE
I
22D,
WHAT
IS
YOUR SPOUSE’S VA
BIRTh?
(month,
day.
year)
SOCIAL SECURITY
NUMBER?
I
ALSO
A
VETERAN?
I
FILE
NUMBER
(if
any)?
~
ElYES
ElN0
22E.
DO
YOU
LIVE
WITH
YOUR
SPOUSE?
I
22F. WHAT
IS
YOUR SPOUSE’S
ADDRESS? (Number
and
street
or
rural
route, city
or
P.O.,
I
State,
ZIP
Code
and
country)
(II
“Yes,~
skip
to
Section
Vt)
I
El
YES
El
NO
(tf”No,’
complete
Items
221’-
22H)
22G.
TELL
US
THE
REASON
WHY YOU ARE
NOT
LIVING
WITh
YOUR
SPOUSE
I
22H. HOW
MUCH
DO
YOU
CONTRIBUTE MONTHLY
TO
YOUR
(I.e.:
fitness.
work, etc.)
SPOUSE’S SUPPORT?
S
SECTION
VI:
DEPENDENT
CHILDREN
(COMPLETE
IF
YOU
HAVE
DEPENDENT
CHILDREN)
Note
-
Skip
to
Section
VIII
you have
no
dependent
children.
(Check
a/I
that apply)
23A.
NAME
OF
DEPENDENT
238.
DATE
AND 23C.
SOCIAL
CHILD
PLACE
OF
BIRTH
SECURITY
23D.
23E.
231’.
230.
I
23H.
231.
23.1.
CHILD
lS-23VEARS
SERIOUSLY
CHILD
PREVIOUSLY
(First,
middle
initial,
last)
(city,
state
or
country)
NUMBER
BIOLDGICAI_
ADOPTED STEPCHILD
OLD
(in
schcct)
I
DISABLED MARRIED
MARRIED
El El
El
El
El
El
El
El El
El
El
El El El
El
El
El El El
El
El
Note
-
In
Items
24A through
24D, tell
us
about
the
children
listed
in
Item
25A
who
do
not
live
with
you.
248.
CHILD’S
COMPLETE
ADDRESS
.
240.
NAME
OF
PERSON
THE
CHILD
24D,
MONTHLY
AMOUNT
YOU
24A.
NAME
OF
DEPENDENT
CHILD
(Number
and
street
or
rural
route, city
or
P.O.,
city,
LIVES
WITH (If
applicable)
CONTRIBUTE
TO
THE
CHILD’S
(First,
middle
initial, las:)
State,
ZIP
Code
and
country)
SUPPORT
S
S
S
VA
FORM
2IR52TEZ.
APR
2016
Page
6
Page 44
SECTION VII:
INCOME
VERIFICATION
-
NET
WORTH
(MUST
COMPLETE)
25.
NET
WORTH
(DO
NOT
LEAVE
ANY
ITEMS
BLANK.
If
your
household
has
no
net
worth
in
a
particular source.
write
“0”
or
“none”)
Report
total
net
worth
for
your
household. You must report
your
net
worth
and
the
net
worth
of
your dependents
(spouse,
child.
etc.).
if
any.
Identify
the
specific
owner
for
each
net
worth source,
yourself
or
another
person
in
your
household,
as
applicable.
SOURCE’
AMOUNT
OWNER SOURCE AMOUNT OWNER
CASH/NON-INTEREST
REAL
PROPERTY
BEARING
BAS’IK
(Not
your
home,
vehicle,
ACCOUNTS
s
furniture,
or
clothing)
INTEREST-BEARING
\LL
OTHER
PROPER’fl
BANK
ACCOUNTS
(Please
write
source)
s
IRA’S,
KEOGH PLANS,
\LL
OTHER PROPERT’i
ETC.
s
(Please
write
sorsrcej
S
STOCKS.
BONDS.
Ut
H~R
ft”rovlde
source)
MUTUAL FUNDS,
ETC.
s
I
s
SECTION
VIII:
INCOME
VERIFICATION
-
MONTHLY
INCOME
(MUST
COMPLETE)
26.
GROSS
MONTHLY
INCOME
(DO
NOT
LEAVE
ANY
ITEMS BLANK.
line
income
was
received
from
a
particular
source, write
‘0”
or
‘none”)
Report
total
monthly income
for
your
household.
You
must
report
your
income
and
the income
of
your
dependents
(spouse,
child, etc.),
if
any.
Identify
the
specific
income
recipient
for
each
income
source,
yourself
or
another
person
in
your
household,
as
applicable.
SOURCE
AMOUNT
RECIPIENT
SOURCE AMOUNT
RECIPIENT
SOCIAL SECURITY SERVICE
RETIREMENT
S
$
SUPPLEMENTAL
SECURIr
SOCIAL SECURITY
INCOME
(SSI)/PUBLIC
S
ASSISTANCE
$
U
I
Hb’t
f&rovzde
source)
U.S.
CIVIL
SERVICE
s
$
U.S.
RAILROAD OTHER (Provide
source)
RETIREMENT
~
$
BLACK
LUNG
OTHER
(Provide
source)
BENEFITS
5
$
SECTION
IX:
EXPECTED
INCOME
(MUST
COMPLETE)
27.
EXPECTED
INCOME.
NEXT
12
MONTHS (DO
NOT
LEAVE
ANY
ITEMS
BLANK.
If no
income
was received
from
a
particular
source,
write
‘0”
or
‘none’)
Report expected
total
household
Income
for
the
next
12
months. You
must
report
your
expected
income
and
the
expected
income
of
your
dependents
(spouse,
ctiild, etc.).
If
any.
Identi~’
the
specific
income recipient
for
each
income
source,
yourself
or
another
person
in
your
household,
as
apptcable.
SOURCE
AMOUNT
RECIPIENT SOURCE AMOUNT
RECIPIENT
S
OTHER INCOME
GROSS
WA
E
AND EXPECTED
(Provide
source
SALARY
$
GROSS
WAGES
AND
I
OTHER
INCOME
SALARY EXPECTED
(Provide
source
$
TOTAL
DIViDENDS AND
~
$
SECTION
X:
MEDICAL,
LEGAL,
OR
OTHER
UNREIMBURSED
EXPENSES
(MUST
COMPLETE)
28.
MEDICAL.
LEGAL.
OR
OTHER
UNREIMBURSED
EXPENSES
(IF
NONE
WRITE
“0’
OR
‘NONE”)
Report
your family
medical
expenses
and
certain
other
expenses
actually
paid
by
you
that
may
be
deductible
from
your
income.
Show
the
amount
of
unreimbursed
medical
expenses,
including
the
Medicare deduction you
paid
for
yourself
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
paid
by
you
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
paid
for
courses
of
education,
including
tuition,
fees,
and
materials.
Show
medical,
legal
or
other
expenses
you
paid
because
of
a
disability
for
which civilian
disability
benefits
have
been
awarded.
When
determining your
income, we
may
be
able
to
deduct
them
from
the
disability
benefits
for
the
year
in
which
the
expenses
are
paid.
Do
not
include
any
expenses
for
which you
were
reimbursed.
PURPOSE RELATIONSHIP
OP
PERSON
DATE
PAID
PAID
TO
(Name
of
doctor,
AMOUNT
PAID
BY
YOU
(mrWddlyy)
(Doctor’s
fees,
hospital
charges,
attorney
fees,
tuition,
hospital,
pharmacy,
etc.)
FOR WHOM
EXPENSES
PAID
education
materials,
etc.)
(Spouse,
child.
etc.)
$
S
S
~
VA
FORM
21P’527EZ,
APR 2016 Page
7
Page 45
SECTION
Xl:
DIRECT
DEPOSIT INFORMATION
(MUST
COMPLETE)
The
Department
of
Treasury requires
all
Federal benefit
payments
be
made
by
electronic
funds
transfer
(EFT),
also called
direct
deposit
Please attach
a
voided
personal check
or
deposit
slip
or
provide the information
requested
below
in
Items
29, 30,
and
31
to
enroll
in
direct
deposit
If
you
do
not
have
a
bank
account,
you
must receive
your
payment through Direct Express Debit
MasterCard
To
request
a
Direct
Express
Debit
MasterCard you
must
apply
at
vnnw
usdiractexoress
cam
or
by
telephone at
1-800-333-1795
If
you
elect
not
to
enroll,
you
must
contact representatives
handling
waiver requests for
the
Department
of
Treasury
at
1-888-224-2950
They
will
encourage your
participation
in
EFT
and
address
any
questions
or
concerns
you
may
have.
29
ACCOUNT
NUMBER
(Check
the
appropriate box
and pro~ide
the
account
number
or
simply
wnie
‘Estabhshed’
if
you
have
a
direct
deposit with
VA)
L
CI4ECKNG
SAVNGS
H
CERTIFYTHAT
I
DONOT
HAVEANACCOUNTWITi-IAFINANCIAL
I
INSTITUTION
OR
CERTiFIED
PAYMENT AGENT
Account
No
Account
No
___________________
30
NAME
OF
FINANCIAL
INSTITUTION
(Please
provide the
name
of
the
bank
where
31
ROUTiNG
ORT~NSIT
NUMBER
(The
first
nine
numbers
located
you
want
your
o~rect
deposit)
at
the
bottom
left
of
your
check)
SECTION
XII:
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
authonze
ary
person
or
entity,
inokjding
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
have
received
the
notice
attacned
to
this
application
titled
Notice
to
Veteran
of
Evidence
Necessary
to
SubstanUale
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,
suoh
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
32
indicating
that
I
~a,n~i
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
32,
The
FDC
Program
Is
designed
to
rapidly
process
compensation
or
pension claims received with
the
evidence
necessary
to
decide
the
claim
VA will
automaticallyconsider
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
oecaUse
you
plan
to
submit
further
evidence
in
support of
your
claim
Lii
DO
NOT
want my
claim
considered
for
rapid
processing
under
the
FDC
Program because
I
plan to
submit
further
evidence
in
support
of
my
claim
33A
VETERAN’SSIGNATuRE(REQtJIRED)
338
DATESIGNED
SECTION XIII:
WITNESSES
TO
SIGNATURE
(MUST
COMPLETE
ONLY
IF VETERAN
SIGNED ITEM
33A
WITH
AN
“X”)
34A.
SIGNATURE
OF
WITNESS
(If
veteran signed
above
using
an
iC)
343.
PRINTED NAME
AND
AODRESS
OF
WITNESS
35A.
SIGNATURE
OF
WITNESS
(If
veteran signed above
using
an
~X’)
356 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
lj,&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,
58VA21122128,
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,
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
0MB
control number
is
displayed.
You
are
not
required
to
respond
to
a
collection
of
information if
this
number
is
not
displayed.
Valid
0MB
control
numbers
can
be
localed
on
the
0MB
Internet
Page
aty~,yseoinfo.oovlDublicfdol
PRAMain.
If
desired,
you
can
call
1-800-827-1
000
to
get
information
on
where
to
send
comments
or
suggestions
about
this
form.
VA
FORM
21P-527Ez,
APR 2016
Page
8
Page 46
Department
of
~
Veterans
Affairs
NOTICE
TO
SURVIVOR
OF
EVIDENCE
NECESSARY
TO
SUBSTANTIATE
A
CLAIM
FOR
DEPENDENCY AND
INDEMNITY
COMPENSATION,
DEATH
PENSION,
AND!OR
ACCRUED
BENEFITS
(This notice
is
applicable
to
survivors
claims
for: Death
Pension Dependency
Indemnity
Compensation
(DIC)
DIC
under
38
U.S.C.
1151
•
Increased
Survivor
Benefits
Based on
Need
for
Aid
and
Attendance or
Being
Housebound
•
Accrued
Benefits
Benefits
Based on
a
Veteran’s
Seriously
Disabled
Child)
Use
this
notice
and
the
attached
application
to
submit
a
claim for
DIC,
Death
Pension,
and/or
Accrued
Benefits.
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
DIC,
Death
Pension,
and/or
Accrued
Benefits,
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
2
l-526EZ,
Application
for
Disability
Compensation
and Related
Compensation
Benefits.
If
you
are
making
a
claim for
veterans
non
service-connected
pension benefits,
use
VA
Form 21P-527FZ,
.4pplication
for
Pension.
VA
forms
are
available
at
www.va.~ov/vaforms.
FDC
Criteria
(Claim(s)
for
DIC,
Death
Pension,
and/or
Accrued
Benefits)
1.
Submit
your
claim
on
a
signed
and
completed
VA
Fonn
2
lP-534FZ, Application
for
D1C,
Death
Pension,
and
or
Accrued
Benefits
(Attached).
2.
Submit simultaneously
with
your
claim:
A
copy
of
the
veteran’s
Death
Certificate
(unless
he
or
she
died
on
active
duty);
AND
If
claiming
death
pension:
•
All
necessary
income
and
net-worth
information
•
Jf
claiming
death pension
with
increased
survivor
benefits,
a
completed
VA
Form
21-2680,
Examination
for
Housebound
Status
or
Penn
anent
Need/or
Regular
Aid
andAttendance,
and
a
completed
VA
Form
21-0779,
Request
for
Nit
rsing
Home
Infonnation
in
Connection
with
Claim
forAid
and Attendance
If
claiming
DIC:
•
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,
that support
your claim
•
Any
and
all
Service
Treatment
and
Personnel Records
in
the
custody
of
the
veteran’s
Guard or
Reserve
Unit(s)
•
If
claiming
PlC
as
the
parent
of
the
veteran,
all
necessary
income
and
net-worth information
and,
if
claiming
benefits
as
the
foster
parent
of
the veteran,
a
completed
VA
Form
21P-524,
Stat
ement
of
Person
Claiming
to
Have
Stood
in
Relation
of
Parent
•
If
claiming
DIC
with
increased
survivor
benefits,
a
completed
VA
Form
2
1-2680,
Examination
for
Housebound
Stat
us
or
Pennanent
Need
for
Regular
Aid
and Attendance,
and
a
completed
VA
Form
21-0779,
Request/or
Musing
Home
Information
in
Connection
wit/i
Claim
forAid
and
.4
ttendance
Requirements
for
Certain
Claimants:
Under
the
circumstances shown
below, you
must
also
submit
simultaneously
with
your
claimn:
•
If
claiming
benefits
as
the
surviving
spouse
of
the
veteran,
a
copy
of
your
marriage
certificate
showing
your
marriage
to
the
veteran,
or
if
claiming
benefits
for
a
child
or
biologicalladoptive parent
of
the
veteran,
a
copy
of
the
birth
certificate
or
court
record
of
adoption showing
relation
to
the
veteran
•
If
claiming
benefits
for
a
child
of
the
veteran
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
(helpless)
child
of
the
veteran,
all,
if
any,
relevant,
private
medical
treatment
records
for
the
child’s pertinent
disabilities
3.
Report
for
any
VA
medical
examinations
VA
determines
are
necessary
to
decide
your
claim.
VA
FORM
21
P-534EZ
SUPERSEDES
VA FORM
21-534EZ,
JUN
2014,
Page
1
JUL
2015
WHICH
WILL
NOT
BE
USED.
Page 47
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.
If
your claim
involves
a
disability
the
veteran
had
before
entering
sen•’ice
and
that
was
made
worse
by
service,
please
provide
any
information
or
evidence
in
your
possession
regarding
the
health
condition
that
existed
before
the
veteran’s
entry
into
service.
WHEN YOU
SHOULD
SEND
WHAT
WE
NEED
F’DC
Program (Optional
Expedited
Process)
Standard
Claim
Process
You
must:
We
strongly
encourage
you
to:
.
Send the
information
and
evidence
simultaneously
with
•
Send
an)’
information
or
evidence
as
soon
as
you
can
your claim
If
you
submit
additional
information
or
evidence
after
you You
have up
to one
year
from
the
date
we
receive
the
claim
to
submit
your
“fully
developed”
claim,
then
VA
will
remove
the
submit
the
information
and
evidence
necessary
to
support
your
claim
from
the
FDC
Program
expedited
process
and process
claim.
If
we
decide the
claim
before
one
year
from
the
date
we
it
in
the
Standard
Claim
process.
If
we
decide
your
claim
before
receive
the
claim,
you
will
still
have
the
remainder
of
the
one
year
from
the
date
we receive
the
claim,
you
will
still
have
one
year
period
to
submit
additional
infonnation
or
evidence
the
remainder
of
the
one-year
period
to
submit
additional
necessary
to
support
the
claim.
information
or
evidence
necessary
to
support
the
claim.
WHERE TO
SEND
INFORMATION
AN]) EVIDENCE
Mail
or
take
your
application
and any
eyidence
in
support
of
your
claim
to
the
closest
VA
regional
office.
VA
regional
office
addresses
are
available
on
the
Internet
at
www.va
.
nov/directory.
VA
FORM
21P-534EZ, JUL
2015
You
must:
FDC
Program (Optional
Expedited
Process)
Standard Claim
Process
•
Submit
your
claim
in
accordance
with
the
“FIX
Criteria”
(see
page
I)
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
w’e
can
request
it
from
the
person
or
agency that
has
it
VA
w’ill:
HOW
VA
WILL
HELP YOU
OBTAIN
EVIDENCE
FOR
YOUR
CLAIM
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
w’ith
an
opportunity
to
submit
the
information
or
evidence.
Iris
j’our
responsibility
to
make
sure
we
receive
all
requested
records
that
are
not
in
the
possession
of
a
Federal
department
or
agency.
FUC
Proaram (Optional
Expedited
Process)
Standard
Claim
Process
•
Retrieve relevant
records
from
a
Federal
facility,
such
as
a
VA
medical
center,
that
you
adequately
identify
and
authorize
VA
to
obtain
VA
will:
•
Retrieve
relevant records
from
a
Federal
facility
that
you
adequately
identify
and
authorize
VA
to
obtain
Make
every
reasonable
effort
to
obtain
relevant
records
not
held
by
a
Federal
facility
that
you
adequately
identify
and
authorize
VA
to
obtain.
These
ma)’
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
Page
2
Page 48
WHAT
THE EVIDENCE MUST
SHOW TO
SUPPORT
YOUR
CLAIM
If
you
arc claiming...
See
the
evidence
table
titled...
Needs-based
benefits
based
on
the
veterans
wartime
service.
Death
Pension
The
veterans
death
was
related
to his
or
her
service
~DIC).
OR
.
DIC
benefits
because
the
veteran
was
receiving
or
entitled
to
Dependency
and
Indemnity
Compensation
~DIC)
receive
benefits
for
a
service-connected
disability
rated
totally
disabling.
The
veterans
death
was
a
result
of
VA
medical
treatment,
,,
~
. . .
DIC
under
~8
U.S.C.
lbl
vocational
rehabilitation,
or
compensated
work
therapy.
DIC
and
it
was
previously
denied
by
VA.
Reopened
DIC
Increased death
pension or
DIC
benefits
because
your
disabilities
.
. .
Increased
Survivor
Benefits
Based
on
Need
for
Aid
and
cause
you
to
be
in
need
of
aid
and
attendance
or
to
be
confined
.
Attendance
or
Being
Housebound
to
your
residence.
You
are
eligible
to
the
benefits
that
were
due
to
the
veteran
at
.
, Accrued
Benefits
the
time
of
the
veterans
death.
You
are
eligible
to
the
benefits
because
a
child
of
the
veteran
is
.
I-Ielpless
Child
severely
disabled.
EVIDENCE
TABLES
Death
Pension
To
support
your
claim for
death
pension
benefits,
the
evidence must
show:
I.
The
veteran
met
certain
minimum
requirements regarding active
service
during
a
period
of
war.
Generally,
those
requirements
involve:
.
90
days
of
consecutive
service,
at
least one
day
of
which
was
during
a
period
of
war;
OR
•
90
days
of
combined
service
during
at
least
one
period
of
w’ar;
(Note
if/he
veteran~s
service
began
after
September
7,
1980,
additional
length-of
service
requirements
may apply,
tynicaliv
requiring
two
years
of
continuous service
or
completion
of
active-duty
obligations.)
OR
any
length
of
active service
during
a
period
of
war
when:
~
At
the
time
of
death, the
veteran
was
receiving
(or
entitled
to
receive)
VA
disability
compensation or
retirement
pay
for
a
service-connected
disabili~’;
OR
•
The
veteran
was
discharged
from
active service
due
to
a
service-connected
disability.
2.
Your
net
worth
and
income
do
not
exceed
certain
requirements.
Dependency and
Indemnity
Compensation
(DIC)
To
support
a
claim
for
Dependenc3
and
Indenmib
Compensation
(DIC)
benefits
based
on
a
sen
ice-connected
disabilit3
established
dunng
the
~eteran’s
lifetime,
the
es
idence
must
show
•
The
veteran
died
while
on
actn
e
sen
ice,
OR
•
The
veteran
had
a
sen
ice-connected
disabilit3
(ies)
that
was
either
the
pnncipal
or
contributor3
cause
of
the
eteran’s
death
OR
•
The
~eteran
died
from
non
sen
ice-connected
mlury
or
disease
AND
was
recen ing, or
entitled
to
receive
VA
compensation
for
a
sen ice-connected
disability
rated
totally
disabling
•
For
at
least
103
ears
immediately
before
death,
OR
•
For
at
least
5
years
after
the
eteran’s
release
from
active
dut3
preceding
death,
OR
•
For
at
least
1
year
before
death,
if
the
~eteran
was
a
former
prisoner
of
war
who
died
after September30
1999
To
support
a
claim for
DIC
benefits
based
on
a
disabilib
that
ii
as
not
sen
ice-connected
or
for
which
the
veteran
did
not
file
a
claim
during
his
or
her
lifetime
the
e~
idence
must show
•
An
injury
or
disease
that
was
incurred
or
aggra~
ated
during
active
service,
or
an
event
in
sen
ice that
caused
an
injury
or
disease,
AND
•
A
physical
or
mental
disability
that
was
either
the
pnnciple
or
contnbutoiy
cause
of
death
This may
be
shown
by
medical
evidence
or
by lay
evidence
of
persistent
and
recurrent
53
mptoms
of
disability
that
were
sisible
or observable.
AND
A
relationship
betw
een
the
disability
associated
with
the
cause
of
death
and
an
injuiy,
disease,
or
event
in
sen
ice
This
may
be
shown
by medical
records
or
medical
opinion
or,
in
certain
cases,
by lay
exidence
VA
FORM
21P5342Z
JUL2015
Page
3
Page 49
EVIDENCE
TABLES
(continued)
Dependency
and
Indenmiti
Compensation
(DIC)
(continued)
To
support’,
our
claim
for
DIC
benefits
based
upon
the
sen
ice
person’s
active
duty
for
training,
the
ex
idence
must
show
The
serx
ice
person was
disabled
dunng
active
dut
for
training
due to
a
disease
or
injun
incurred
in
the
line
of
duN.
and
the
disease
or injur’,
caused
or
contributed
to the
sen
ice
person’s
death
If
VA
granted
sen
ice
connection
for
a
disease
or
injun
dunng
the
sen
ice
person’s
lifetime,
cx
idence
that
the
sen ice-connected
disease
or
injur’,
caused
or
contributed
to
the
sen
ice
person’s death
may
satisf’,
this
requirement
To
support
a
claim
for
DIC
benefits
based
on
a
disabilit~
that
xxas
not
sen
ice-coimected
or
for
winch
the
sen
ice
person
did
not
file
a
claim
during
his
or
her
lifetime
the
ex
idence
must
show
•
The
sen
ice
person
was
disabled
dunng
active
duB
for
training
due to
a
disease
or
injury
incurred
in
the
line
of
dut’,
,
AND
•
A
ph’,
sical
or
mental
disabilit’,
that
was
either
the
principle
or
contnbuton
cause
of
death
This
max be
shown
bx
medical
ex
idence
or
by
lax
cx
idence
of
persistent
and
recurrent
s’,
mptoms
of
disabilit’,
that
w’ere
isible
or
obsenable
AND
•
A
relationship
betw’een
the
pnncipal
or
contnbutory
cause
of
death
and the
disability
due
to
injur’, or
disease
incurred
in
the
line
of
duty
This
max
be
shown
1w
medical
records
or
medical
opinions
or,
in
certain
cases,
b’,
Ia’,
evidence
To
support
‘,our
claim
for
DXC
benefits
based
upon
the
sen
ice
person’s
inactive
dut’,
training
the
evidence
must
show’
‘The
serx
ice
person
died
during
inactive
duB
training
due
to
an
injury
incurred
or
aggrax
ated
in
the
line
of
din’,
or
acute
myocardial
infarction
cardiac
arrest.
or
cerebrovascular
accident
dunng
such
training OR
•
The
serx
ice
person was
disabled
dunng
inactive
duty
training
due
to
an
injury
incurred
or
aggrax
ated
in
the
line
of
duty,
or acute
m’,
ocardial
infarction
cardiac
arrest,
or
cerebrovascular
accident
that
occurred
during
such
training,
and
that
injury
acute
myocardial
infarction
cardiac
arrest
or
cerebrox
ascular
accident
caused
or
contributed to
the
sen’ice
persons
death
If
VA
granted sen
ice
connection
for
an
injur’,,
acute
m’,
ocardial
infarction,
or
cerebrovascular accident
durmg
the
sen
ice
person’s
lifetime,
cx
idence
that
the
sen ice-connected
condition
caused
or
contributed
to
the
sen’ice
person’s
death
may
satisI~’
this
requirement
To
support
a
claim
for
DIC
benefits
based
on
a
disabilit’,
that
was
not
sen ice-connected
or
for which
the
sen
ice
person
did
not
file
a
claim
during
his
or
her
lifetime,
the
cx
idence
must show
•
The
sen
ice
person
was
disabled
durmg
inactive
duty
training
due to an
injury
incurred
or
aggravated
m
the
line
of
dut’,
or
acute
myocardial
mfarction
cardiac
arrest,
or cerebrovascular
accident
that
occurred
dunng
such
training,
AND
•
The
injury,
acute
in’,
ocardial
infarction
cardiac
arrest
or
cerebrox
ascular
accident
caused
or
contributed
to the
serx
ice
person’s death
DXC
under
38
U.S.C.
1151:
In
order
to
support
‘,our
claim
for
DXC
under
38
U.S.C.
1151
the
cx
idence
must
show’
•
The
deceased
eteran
died
as
a
result
of
undergoing
VA
hospitalization,
medical
or surgical
treatment,
examination,
or
training,
AND
•
The
death was
the
direct result
of
VA
fault
such
as
carelessness,
negligence
lack
of
proper
skill,
or
error
in
judgment,
OR
the
direct
result
of
an
event
that
xx
as
not
a
reasonably
e\pected result
or
complication
of
the
VA
care
or treatment,
OR
the
direct result
of
participation in
a
VA
Vocational
Rehabilitation
and
Emplo’,
ment or
compensated
work
therap’,
program
Reopened
DXC:
rn
order
to reopen
a
claim
prex
iously
denied
b’,
VA
xx
e
need
new
and
material
cx
idence
New
and
material
cx
idence
must
raise
a
reasonable
possibility
of
substantiating’,
our
claim
The
ex
idence cannot
sunply
be
repetitix
e
or
cumulative
of
the
cx
idence
xx
e
had
when
we
previously
decided our
claim
VA
will
make reasonable
efforts
to
help
‘,ou
obtain
currently
existing
evidence
How ever,
we
cannot
provide
a
medical examination
or
obtain
a
medical
opinion
until
‘,our
claim
is
successfully
reopened
•
To
qualify
as
new’,
the
cx mdence
must
currently
exist
and
be
submitted
to
VA
for
the
first
tune
•
In
order
to be
considered
material,
the
additional
existing
evidence
must pertain
to the
reason
your
claim
was
previously
denied
VA FORM
21P
5346Z
JUL 2015
Page
4
Page 50
EVIDENCE
TABLES
(Continued)
Dependency
and
hidenmity
Compensation
~DIC)
~‘onti,iued~
In
order
to
support
your
claim
for
increased
survivor
benefits
based
on
the
need
for
aid and
attendance,
the
evidence
must
show’:
•
you
have
corrected
vision
of
5/200
or
less
in
both
eyes;
OR
•
you
have
concentric
contraction
of
the
visual
field
to
5
de~ees;
OR
•
you
are
a
patient
in
a
nursing
home
due
to
mental
or
physical
incapacity;
OR
•
you
require
the
aid
of
another
person
in
order
to
perform
personal
functions
required
in
everyday
living,
such
as
bathing, feeding,
dressing
yourself,
attending
to the
wants
of
nature,
adjusting prosthetic
devices,
or
protecting
yourself
from
the
hazards
of
your daily
enviromnent
(38
Code
of
Federal
Regulation
3.352(a));
OR
•
you
are
bedridden, in
that
your
disability
or
disabilities
requires
that
you
remain
in
bed
apart
from
any
prescribed
course
of
convalescence
or
treatment
(38
Code
of
Federal
Regulation
3.352(a));
OR
In
order
to
support
your
claim
for
increased
benefits
based on
being
housebound,
the
evidence
must
show:
•
you
are
substantially
confined
to
your
immediate
premises
because
of
pennanent
disability
Acenjed
Benefits
To
support
a
claim
for
accrued benefits,
the
evidence
must
show:
•
Benefits
were
due
the
veteran
based
on
existing
ratings,
decisions,
or
evidence
in
VA’s
possession
at
the
time
of
death.
but
the
benefits were
not
paid
before
the
veteran’s death;
AND
•
You
are
the
surviving
spouse,
child,
or
dependent
parent
of
the
deceased
veteran
VA
pays
accrued
benefits
in
the
following
order
of
priority:
1.
Spouse
2.
Children
of
the
veteran
(in
equal
shares)
3.
Dependent
parents
(in
equal
shares)
Helpless
Child:
To
support
a
claim
for
benefits
based on
a
veteran’s
child
being
helpless,
the
evidence
must
show
that
the
child,
before
his
or
her
18th
birthday,
became
pennanently
incapable
of
self-support
due to
a
mental
or
physical
disability.
IMPORT
ANT
If
you
are
certi~’ing
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
recognizes marriages
is
available
at
http://\nvw.va.~ov/opa/marriaae/.
HOW
VA
DETERMINES THE
EFFECT
WE
DATE
If
we grant
a
claim
for
death
benefits,
the
beginning
date
of
your
entitlement
will
generally
be
based
on
when
w’e
received
your
claim
However,
if
VA
received
your claim
within
one
year
of
the
date
of
the
veteran’s
death,
entitlement
will
be
from
the
first
day
of
the
month in
which
the
veteran
died.
The veteran’s
death
certificate
is
evidence
relevant
to
detennining
the
effective
date
of
any
benefits
we award.
Higher
levels
of
benefits
are
available
for
a
veteran’s
surviving
spouse
and/or
parents
who
are
unable
to
perform
certain
activities
of
daily
living
or leave
their
home.
Higher
levels
of
benefits
may
be
effective from
the
date
medical
evidence
first
establishes
entitlement.
For more
information
on the
FDC
Program,
visit
our web
site
at
http://benefits.va.crov/transfonnation/fastclaims/
For
more
information
on
VA
benefits,
visit
our web
site
at
w~nv.va.cov,
contact
us
at
http://iris.va.eov,
or
call
us
toll-free
at
1-800-827-1000.
If
you
use
a
Telecommunications Device
for
the
Deaf
(TDD),
the
number
is
1-800-829-4833.
VA
forms
are
available
at
;vsvw.va.~ov/vafomis.
VA FORM
21P-534EZ,
JUL2015
Page
5
Page 51
0MB
Control
No
2900-0004
Respondent Burden
25
minutes
Expiration
Date
07/31/2018
Department
of
Veterans
Affairs
APPLICATION
FOR
DIC,
DEATH PENSION,
ANDIOR
ACCRUED
BENEFITS
IMPORTANT:
Please
read
the
Privacy
Act
and
Respondent
Burden
on
page
11
before
completing
the
form.
SECTION
I:
PERSONAL INFORMATION (MUST
COMPLETE)
VA
DATE
STAMP
(DO
NOT
WRITE
IN
THIS
SPACE)
1
VETERAN’S NAME
(Last,
flrst,
middle)
2
VETERAN’S
SOCIAL
SECURITY
NUMBER
3
VETERAN’S
DATE
OF
BIRTH
(MM,DD,YYYY)
4
VETERAN’S
SEX
5
HAS
THE VETERAN,
SURVIVING
SPOUSE,
CHILD,
OR
PARENT
EVER
6.
VA
FILE
NUMBER
FILED
A
CLAIM
WITH
VA’
fl
MALE
D
FEMALE
fl
YES
fl
NO
(It
“Yes,” provide
the file
number
in
Item 6)
7
DID THE
VETERAN
DIE
WHILE
ON
ACTIVE DUTY?
8,
WHAT
IS
THE
VETERAN’S
DATE
OF
DEATH?
(MM,DD,YYYY)
~
YES
~
NO
a
WHAT
IS
YOUR
NAME?
(First
middle,
lasl
name)
10.
WHAT
IS
YOUR
RELATIONSHIP
TOTHE
VETERAN?
(Check
one)
fl
SURVIVING SPOUSE PARENT
CHILD
CUSTODIAN
FILING
FOR
CHILD
11.
WHAT
IS
YOUR
SOCIAL
SECURITY NUMBER?
12.
WHAT
IS
YOUR
DATE
OF
BIRTH?
13.
ARE
YOU
A
VETERAN?
(MM,DD,YY’fl’)
~
YES
D
NO
14A.
WHAT
IS
YOUR
ADDRESS?
14B.
YOUR
TELEPHONE NUMBER(S) (include
Area
Code)
DAYTIME
Street address,
wral
route,
or
P.O.
Box
Apt.
nUmber
EVENING
( )
City
State
ZIP
Code
Country
CELL PHONE
( )
iSA
YOUR
PREFERRED
E-MAIL ADDRESS
(If
applicable)
1SB.
YOUR
ALTERNATE
E-MAIL
ADDRESS
(If
applicable)
16.
WHAT
ARE
YOU
CLAIMING?
(Check
all
that
apply)
fl
DEPENDENCY
AND
INDEMNITY COMPENSATION
(DIO)
fl
DEATH
PENSION
ACCRUED
BENEFITS
SECTION
II:
VETERAN’S
SERVICE
INFORMATION
(COMPLETE
ONLY/F
THE
VETERAN
WAS
NOT
RECEIVING
VA
COMPENSATION
OR
PENS/ON
BENEFITS
AT
THE
TIME
OF
flEA
TH)
(Skip
to
Section
Il/if
the
veteran
was
receiving
VA
compensation
or
pension
benefits
at
the
time
of
his
or
her
death)
17A.
DID THE
VETERAN
SERVE
UNDER
ANOTHER NAME?
17B.
PLEASE
LIST
OTHER NAME(S) THE
VETERAN SERVED
UNDER:
D
YES
H
NO
(It”Yes,”
complete
Item
17B)
(lt”No,”skipto
Item
ISA)
18A.
VETERAN
ENTEREDACTIVE
SERVICE
ON
(MM,DD,YYYY)
~
(MM,DD,YYYf)
18D~
DO
THE
VETERAN
SERVE
IN
A
COMBAT
ZONE SINCE
9-11-2001?
18E.
PLACE
OF
LAST
SEPARATION
19A.
WAS THE
VETERAN ACTIVATED
TO FEDERAL ACTIVE DUTY UNDER
AUTHORITY
OF
19B.
DATE
OF
ACTIVATION
(MM,DD,YYTY)
TITLE
10,
U.S.C.
(National
Guard)?
H
YES
H
NO
(If”Yes,”
answer
Items
19B,
19C
and
19D)
19C.
WHAT
IS
THE NAME
AND
ADDRESS
OF
THE VETERAN’S
RESERVE/NATIONAL
GUARD
UNIT?
19D.
WHAT
IS
THE TELEPHONE
NUMBER
OF
THE
RESERVE/NATIONAL
GUARD
UNIT?
(Include
Area
Code)
( )
20A.
WAS
THE
VETERAN
EVER
A
PRISONER
OFWAR?
20B.
DATES OF
CONFINEMENT
H
YES
H
NO
(II
“Yes,”
complete
Item
209)
(If
“No,”
skip
to
Secticn
Ill)
FROM:
TO:
VA FORM
21
P-534EZ
SUPERSEDES
VA FORM
21-534EZ,
JUN
2014,
WHICH
WILL
NOT
BE
USED. Page
6
JUL
2015
Page 52
SECTION
III:
MARITAL
INFORMATION
(COMPLETE
ONLYIF
CLAIMING BENEFITS AS
THE
SURVIVING SPOUSE OF
THE
VETERAN)
(Skip
to
Section/V
if
you
are
NOT
claiming
benefits
as
the
surviving
spouse
of
the veteran)
TELL
US
ABOUT
THE
VETERANS
MARRIAGES
21A
HOW
MANY
TIMES
WAS
THE
VETERAN MARRIED
(including marriage
to
you)’?
21B.
DATE
(month,
day,
year)
and
PLACE
OF
MARRIAGE
(city,
state
or
counlry)
21C
TOWHOM
MARRIED
(first,
middle,
last
name)
21D.
TYPE
OF
MARRIAGE
(ceremonial,
common-law,
procy.
tribal,
or
other)
21E
HOW MARRIAGE
TERMINATED
(death,
divorce)
210
IF
YOU
INDICATED
‘OTHER’
AS
TYPE
OF
MARRIAGE
IN
ITEM
21
D,
PLEASE EXPLAIN:
TELL
US
ABOUT
YOUR
MARRIAGES
22A.
HAVE
YOU
REMARRIEO SINCE THE DEATH
OF
THE
VETERAN?
22S
HOW
MANY
TIMES
HAVE
YOU
BEEN
MARRIED? (including your
marriaga
to
the
veteran)
~
YES
El
NO
22E.
TYPE
OF
MARRIAGE
22R HOW
MARRIAGE
22G.
DATE
(month,
day,
year)
TERMINATED
and
PLACE
MARRIAGE
22C.
DATE
(month,
day,
year)
and
PLACE
22D.
TO
WI-lOM
MARRIED
(ceremonial, common-law,
(death,
divorce,
marriage
has
not
TERMINATEO
OF
MARRIAGE
(citylstate
or
country)
(first, middle,
last
name)
proxy,
tribal,
or
other)
been
terminated)
(citylstete
or
country)
22H.
IF
YOU
INDICATED
“OTHER”
AS
TYPE
OF
MARRIAGE
IN
ITEM 22E,
PLEASE
EXPLAIN:
23.
WAS
A
CHILD
BORN
TO
YOU
AND THE
VETERAN
DURING YOUR MARRIAGE
I
24.
ARE YOU EXPECTING THE
BIRTH
OF
THE VETERAN’S CHILD?
OR
PRIOR
TO YOUR MARRIAGE?
I
DYES
DNO
flYES
flNo
25.
DID YOU
LIVE
CONTINUOUSLY
WITH THE
VETERAN
FROM
THE
DATE
26.
WHAT
WAS THE CAUSE
OF
SEPARATION?
GIVE THE
REASON, DATE(S)
AND
OF
MARRIAGE
TO
THE
DATE
OF
HISIHER
DEATH?
DURATION
OF
THE
SEPARATION
(IF
THE
SEPARATION
WAS
BY
COURT
ORDER,
ATTACH
A
COPYOP
THE
ORDER)
El
YES
El
NO
(If
“No,”
complete
Item
26)
27.
AT
THE TIME
OF
YOUR
MARRIAGE
TOTHE
VETERAN,
WERE
YOU
AWARE
OF
ANY
REASON
THE MARRIAGE
MIGHT
NOT
BE
LEGALLY
VALID?
El
YES
El
NO
(If
“Yes,”
provide
explanation):
SECTION
IV:
DEPENDENT
CHILDREN
(COMPLETE
ONLY/F
CLAIMING BENEFITS
FOR
A
CHILD(REN)
OF
THE
VETERAN)
(Skip
to
Section
Vif
you
are
NOT
c/aiming benefits
for
a
chlldfren)
of
the
veteran)
28B.
DATE (month,
day,
28C.
SOCIAL
(CheCk
all
that
apply)
28A.
NAME
OF
CHILD
year)
and
PLACE OF
SECURITY
28D.
28E,
28F.
28G.
28H.
281.
28J
CHILD
8-23
YEARS
SERIOUSLY
CHILD
PREVIOUSLY
(First,
middle
initial,
last
name) BIRTH
NUMBER
BIOLOGICAL
ADOPTED STEPCHILD
OLD
(in
school) DISABLED
MARRIED MARRIED
(citylstate
or
country)
El El
El
El El El
El
El El
El
El El
U
U
El El
El
El
U
El
El
If
claiming benefits
as
the
surviving
spouse
or
custodian
filing
for
a
child,
in
items
29A
through
29D
tell
us
about the
children
listed
in
Item
28A who
do
not
live
with
you.
21F.
DATE
(month,
day,
year)
and
PLACE MARRIAGE
TERMINATED
(citylstate
or
country)
29A.
NAME
OF
CHILD
29B,
CHILD’S COMPLETE
ADDRESS
(First,
middle
initial,
last
name)
(Number
and
street
or rural
route,
city
or
P0,
city,
29C.
NAME
OF
PERSON
THE
CHILD
29D.
MONTHLY
AMOUNT
YOU
State.
ZIP
Code
and
country) LIVES WITH
(If
applicable)
CONTRIBUTE TO
THE
CHILD’S
SUPPORT
$
$
$
VA FORM
21P-534EZ,
JUL 2015
Page
7
Page 53
SECTION
V:
VETERANS
PARENT
(COMPLETE
ONLY
IF
CLAIMING
BENEFITS
AS
THE
PARENT
OF
VETERAN)
(Skip
to
Section
VI
if
you
are
NOT claiming benefits
as
the
parent of
a
veteran)
30k
WHAT
IS
YOUR
MARITAL
STATUS?
(Check
one)
D
MARRIED
AND LIVE
WITH
~
MARRIED
AND
LIVE
WITH SPOUSE
WHO
SEPARATED,
MARRIED
BUT
OTHER PARENT
OF
VETERAN
L~J
IS
NOT THE
OTHER
PARENT
OF
THE
VETERAN
NOT LIVING WITH SPOUSE
~
DIVORCED
WIDOWED
D
NEVER
MARRIED
30B.
IF
YOUR
MARRIAGE
HAS
ENDED,
PLEASE
SPECIFY
THE
DATE (month,
day,
year)
AND
HOW MARRIAGE ENDED
(death,
divorce)
30C.
IF
YOU
ARE
SEPARATED, WHAT
WAS
THE CAUSE
OF
THE
SEPARATION?
GIVE THE
REASON,
DATE(S) AND
DURATION
OFTHE
SEPARATION
(IF
THE
SEPARq
TION WAS
av’
COURT
ORDER,
ATTACH
A
COPY OF
THE
ORDER)
31A.
WHAT
IS
YOUR
SPOUSE’S
NAME?
(First,
middle
initial, last
name)
31B
WHAT
IS
YOUR
SPOUSE’S
DATE
SiC. WHAT
IS
YOUR
SPOUSE’S
SOCIAL
(Skip
to
Item
32A
if
never
married
or
no
longer
married)
OF
BIRTH?
(MM,DD,’YYYY)
SECURITY
NUMBER?
31D.
IS
YOUR SPOUSE ALSO
A
VETERAN?
SIE.
WHAT
IS
YOUR
SPOUSE’S
VA
FILE
NUMBER?
(If
applicable)
~
YES
LI
NO
(If
‘Yes,”
complete
Item
31
E)
32k
WAS
THE
VETERAN
A
MEMBER
OF
YOUR
HOUSEHOLD
OR
UNDER
YOUR
32B.
DATE(S)
OF
PARENTAL
CONTROL
(If
veteran
did not live
in
your household
PARENTAL
CONTROL
AT
ALLTIMES
BEFORE HE/SHE
REACHED
THE AGE continuously before
age
18
provide
the
time
period (dates)
when he/she
was
OF
MAJORITY
(AGE
18
IN
MOST
STATES)?
underyour
parental
control)
C
YES
NO
(If”Yes,”
skip
to
Item
34)
(MM
DDYY’fl’)
to
(MM
DD
YYYY)
(MM
DDYYYY)
to
(MM
DD
YYYY)
32C.
WHY
WASt~l’T
THE
VETERAN
A
MEMBER
OF
YOUR
HOUSEHOLD
OR
UNDER
YOUR
PARENTAL
CONTROL
AT
ALL
TIMES BEFORE
HEJSHE
REACHED
THE
AGE
OF
MAJORITY?
(Explain
fully)
33.
NAME AND
ADDRESS
OF EACH PERSON
WHO
ASSUMED PARENTAL
CONTROL
OVER THE
VETERAN OUTSIDE
THE DATE(S)
SHOWN
IN
ITEM
32B
A.
NAME
(FIRST, MIDDLE,
LAST)
B.
ADDRESS
Street
address,
rural
route,
or
P.O.
Box
Apt.
number
City State
ZIP
Code
Country
Street
address,
rural
route,
or
P0.
Box
Apt.
number
City State
ZIP
Code
Country
34.
IF
YOU
ARE NOT
THE
BIOLOGICAL
PARENT
OF
THE
VETERAN, PROVIDE THE
NAMES
OF
THE
BIOLOGICAL
PARENTS,
IF
DECEASED,
PROVIDE
THE
DATE
OF
DEATH
A.
NAME
(FIRST, MIDDLE,
LAST)
B.
DATE OF
DEATH
(MM,DD,YYW)
SECTION
VI:
DIC
(COMPLETE
ONLY
IF CLAIMING DEPENDENCY AND
INDEMNITY
COMPENSATION
(DIC))
(Skip
to
Section
VII
if
you
are
NOT
claiming
DIC)
36.
WHAT BENEFIT
ARE YOU
CLAIMING?
fl
DIO
010
under
38
U.S.C.
1151
(RARE)
36.
LIST
ANY
VA
MEDICAL
CENTERS WHERE
THE
VETERAN
RECEIVED
TREATMENT
PERTAINING TO
YOUR CLAIM
AND
PROVIDE
TREATMENT
DATES:
A.
NAME
AND
LOCATION
OF
VA
MEDICAL
CENTER
B.
DATE(S)
OF
TREATMENT
VA FORM
21P-534EZ,
JUL2015
PageS
Page 54
SECTION
VII:
NET
WORTH
(COMPLETE
ONLY
IF
CLAIMING
DEATH PENSION
OR
PARENTS
DIC)
(Skip
to
Section
XI
if
you
are
NOT
claiming death
pension benefits
or
parents
DIC)
37
NET
WORTH
(DO NOT
LEAVE
ANY
ITEMS BLANK
If
your
household
has
no
net
worth
in
a
particular
source,
write
‘Ocr
none)
Report
total
net
worth for your
household. Identify
the
specific owner for
each
net
worth
source,
yourself
or
another
person
in
your
household,
as
applicable
If
you
are the
custodian
filing
for
a
child
of the
veteran, you
must
report
your
net
worth
end
the
child’s
net
worth, if
any.
SOURCE
AMOUNT
OWNER SOURCE
AMOUNT
OWNER
CASHiNON-INTEREST
REAL
PROPERTY
BEARING
BANK
(Not
your
home,
vehicle,
ACCOUNTS
$
furniture,
or
clothing)
$
OTHER
PROPERTY
INTEREST-BEARING
(Provide
source)
BANK
ACCOUNTS
$ $
‘
OTHER
PROPERTY
IRA
5,
KEOGH
PLANS,
(Provide
source)
ETC
$ $
STOCKS,
BONDS, OTHER
(Provide
source)
MUTUAL
FUNDS,ETC.
$ $
SECTION
VIII: GROSS
MONTHLY
INCOME
(COMPLETE
ONLY
IF
CLAIMING
DEATH
PENSION
OR
PARENTS
0/C)
(Skip
to
Section
Xl
if
you
are
NOT
claiming death
pension
benefits
or parents
0/C)
35.
GROSS
MONTHLY
INCOME (DO
NOT
LEAVE
ANY
ITEMS
BLANK.
If
no
income
was
received from
a
particular
source,
write “0”
or
‘none’)
Report total
monthly
income
for
your
household.
Identify
the
specific
income
recipient
for
each
income
source,
yourself
or
another
person
in
your household,
as
applicable.
If
you are the
custodian
filing
for
a
child
of
the
veteran,
you
must
report
your income
and
the
child’s
income,
if
any.
SOURCE AMOUNT RECIPIENT
SOURCE
AMOUNT RECIPIENT
SERVICE
RETIREMENT1
SOCIAL SECURITY
SURVIVOR BENEFIT
PLAN
$
fSBP)
ANNUITY
$
SUPPLEMENTAL
SECURITY
SOCIAL
SECURITY
INCOME
(SSO/PUBLIC
$
ASSISTANCE
$
OTHER
(Provide
source)
U.S.
CIVIL
SERVICE
S
$
U.S.
RAILROAD OTHER (Provide
source)
RETIREMENT
$ $
SLACK LUNG
OTHER
(Provide
source)
BENEFITS
$
$
SECTION
IX:
EXPECTED
INCOME
(COMPLETE
ONLY
IF
CLAIMING
DEATH PENSION
OR
PARENTS
DIC)
(Skip
to
Section
XI
if
you
are
NOT
claiming
death
pension benefits
or
parents 010)
39.
EXPECTED
INCOME
-
NEXT
12
MONTHS
(DO NOT
LEAVE
ANY
ITEMS
BLANK.
If
no
income
was
received
from
a
particular
source,
write
‘C”
or
‘none’)
Report
expected total
household
income
for
the
12
month period
following
the
veteran’s
death,
If
the
claim
is
filed
more
than
One
year after
the
veteran
died,
report
the
expected
total
household
income
for the
12
month
period
from
the
date
you
sign
this
application.
Identify
the
specific
income
recipient
for
each
income
source,
yourself
or
another
person
in
your
household,
as
applicable,
If
you
are the
custodian
filing
for
a
child
of
the
veteran,
you
must
report
your
expected
income
and
the
child’s
expected
income,
if
any.
SOURCE
AMOUNT RECIPIENT SOURCE AMOUNT RECIPIENT
OTHER
INCOME
EXPEcTED
GROSS
WAGES
AND (Provide
source)
SALARY
$
$
OTHER
INCOME
EXPECTED
GROSS
WAGES
AND
(Provide
source)
SALARY
$
$
OTHER
INCOME
EXPECTED
TOTAL
DIVIDENDS AND
(Provide
source)
INTEREST
$
$
SECTION
X:
MEDICAL,
LAST
ILLNESS,
BURIAL,
OR
OTHER
UNREIMBURSED
EXPENSES
(COMPLETE
ONLY IF
CLAIMING
DEATH
PENSION
OR
PARENTS
0/C)
(Skip
to
Section
XI
if
you
are
NOT
claiming
death
pension
or
parents
0/C)
40
MEDICAL,
LAST
ILLNESS, BURIAL,
OR
OTHER
UNREIMBURSED
EXPENSES
Family
medical
expenses
and
certain
other
expenses
actually
paid
by
you
may
be
deductible
from
your income.
Show
the
amount
of any
continuing
family
medical
expenses
such
as
the
monthly
Medicare
deduction
or nursing
home
costs
you
pay.
Also,
show
unreimbursed
last
illness
and
burial
expenses
and
educational
or
vocational rehabilitation
expenses
you paid.
Last
illness
and
burial
expenses
are
unreimbursed
amounts
paid
by
you
for
the
veteran’s
or
his/her
child’s
last
illness
and
burial
and
the
veteran’s just
debts.
Educational
or
vocational rehabilitation
expenses
are
amounts
paid
for
Courses
of
education,
including
tuition,
fees,
and
materials.
Do
not
include any
expenses
for which
you
were
reimbursed.
If
you receive
reimbursement
after you
have
filed
this
claim,
promptly advise
the
VA
office
handling your
claim.
DATE
PAID
PURPOSE
PAID
TO
(Name
of
nursing
home,
RELATIONSHIP
OF
PERSON
FOR
WNOM
EXPENSES
PAID
AMOUNT
PAID
BY
YOU
(mnVdd~iy)
(Medicare
deduction,
nursing
home
costs,
hospital,
funeral
home,
etc.)
(Spouse,
child,
etc)
burial_expanses,_etc.)
S
S
S
$
$
VA FORM
21P-534EZ, JUL
2015
Page
9
Page 55
SECTION
XI:
DIRECT
DEPOSIT
INFORMATION
(MUST
COMPLETE)
The
Department
of
Treasury
requires
all
Federal
benefit
payments
be
made
by
electronic
funds transfer
(EFT), also
called
direct
deposit.
Please
attach
a
voided personal
check
or
deposit
slip
or
provide
the
information
requested
below
in
Items
41, 42,
and
43
to
enroll
in
direct
deposit.
If
you
do
not
have
a
bank account,
you
must
receive
your
payment
through
Direct Express
Debit
MasterCard.
To
request
a
Direct
Express
Debit
MasterCard
you
must
apply
at
~vw.usdirectexDress.com
or
by
telephone
at
1-800-333-1795.
If
you
elect
not
to
enroll,
you
must
contact representatives
handling
waiver
requests
for the Department
of
Treasury
at
1-888-224-2950.
They
will
encourage
your
participation
in
EFT
and
address
any
questions
or
concerns
you
may
have.
41.
ACCOUNT NUMBER
(Check
the
appropriate
box
dnd
provide
the
account
number,
or
simply write
“Established”
if you
have
a
direct deposit with
VA.)
E
D
I
CERTIFY
THAT
I
DO
NOT
HAVE
AN
ACCOUNT
WITH
A
CHECKING
SAVINGS
FINANCIAL INSTITUTION
OR
CERTIFIED
PAYMENT AGENT
Account
No.:
Account
No.:
42.
NAME
OF
FINANCIAL
INSTITUTION
(Please provide
the
name
of
the
bank
43
ROUTING
OR
TRANSIT
NUMBER
(The
first
nine
numbers located
where
you
want your
direct
deposit)
at
the
bottom
left
of
your check)
SECTION
XII
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
except
protected
health
information,
and
I
waive
any
privilege
which makes
the
information
confidential.
I
certify
I
have
received
the
notice
attached
to
this
application titled Notice
to
Survivor
of
Evidence
Necessary
to
Substantiate
a
Claim
for
Dependency
Indemnity
Compensation,
Death Pension,
and/or Accrued
Benefits.
I
certify
I
have
enclosed
all
information
or
evidence
that
will
support
my
claim,
to
include
an
identification
of
relevant records
available
at
a
Federal faoility,
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 44,
indicating
that
I
do
not
want
my
claim
considered
for
rapid
prooes~ing
in
the Fully
Developed
Claim
(FDC)
Program because
I
plan
to
submit
further
evidence
in
support
of
my
claim.
44.
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
box
below
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.
100
NOT
want
my
claim
considered
for
rapid
processing
under
the
FDC
Program
because
I
plan
to
submit
further
evidence
in
support
of
my
claim.
45k
CLAIMANTS
SIGNATURE (REQUIRED)
(Sign
in
ink)
45B
DATE
SIGNED
SECTION
XIII:
WITNESSES
TO
SIGNATURE
(COMPLETE
ONLYIF
CLAIMANT
SIGNED
ITEM 45A
WITH
AN
“X’9
46A
SIGNATURE
OF
WITNESS
(If
claimant signed above
using
an
)C)
(Sign
in
ink)
46B
PRINTED
NAME
AND ADDRESS
OF
WITNESS
47A
SIGNATURE
OF
WITNESS
(If
claimant signed
above using
an
X)
(Sign
in
ink)
4TB
PRINTED
NAME
AND
ADDRESS
OF
WITNESS
PRIVACY ACT NOTICE:
The
foms
will
be
used
to
determine
allowance
to
compensation
and(or
pension
benefits
(38
U.S.C.
Slot).
The
responses
you
submit
are
considered
confidential
(38
U.S.C.
5701).
VAmay
disclose
ibe
informationthatyou
provide,
including
Social
Securiw
numbers,
outside
\‘A
ifihe
disclosure
iaauthorized
under
the
PrivacyAct,
includingthe
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
Fedeml
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
ofmoney
owed
to
the
United
States,
litigation
in
which
the
United
Slates
isa
pamy
or
has
an
interest,
the
adsstiniatration
ci’
VA
programs
and
delivery
of
VA
benefits,
verification
of
identity
and
status,
andpersonnel
adssinitvation.
Your
obligation
to
respond
is
required
in
order
to
obtain
or
reiain
benefits.
Information
that
you
furnish
may
be
utilized
in
compuler
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
Slates
by
vittue
of
your
panieipation
in
any
benefit
program
administered
by
the
Department
of
Vetemna
Affairs.
Social
Security
information:
You
are
required
to
provide
the
Social
Security
number
requested
under
38
U.S.C.
SlOt(cxt).
VA
may
disclose
Social
Security
numbers
as
authorized
under
the
Privacy
Act
and,
specifically
may disclose
thens
forpurpotes
stated
above.
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
ass
average
of
25
nsinuies
to
review
the
instn,ctions,
find
the
information,
and
complete
this
form.
VA
cannot
conductor
sponsor
a
collection
of
information
unless
a
t’slid
0MB
control
number
is
displayed.
You
are
not
required
to
respond
to
a
collection
of
information
if
thu
number
ii
not
displayed.
Valid
0MB
control
numbers
can
be
located
on
the
0MB
tntemet
Page
St
www.rrein&govfptdslicfdofl’RAMatn.
If
desired,
you
can
call
1-800-827-1000
to
get
information
on
where
to
send
comments
or
suggestions about
this form.
VA
FORM
21P-534EZ,
JUL2015
Page
10
Page 56
A1\
Department
of
~
Veterans
Affairs
INFORMATION
AND INSTRUCTIONS
TO
HELP
YOU
COMPLETE
THE
AUTHORIZATION
TO
DISCLOSE
PERSONAL
INFORMATION
TO
A
THIRD PARTY
GENERAL
INFORMATION
At
VA,
we
recognize
and
respect
the
importance
of
privacy.
Personal
information
that
we
collect
is
kept
confidential
to
the
extent provided
by
law.
In
accordance
with the
Privacy
Act
and
applicable confidentiality
statutes,
VA
will
only
disclose the
information
in
its
custody
or
control
in
the
following
circumstances:
where
the
individual identifies
the
particular
information
and
consents
to
its
use;
where
disclosure of
the
information
is
required
by
law;
or
where
the
disclosure
is
otherwise
legally
permitted,
including release
for
a
purpose
compatible
with
the
purpose for
which
it
was
collected.
By
law,
VA
must
have
your
written
permission
(an
“authorization”)
to
use
or
give
out
your
claim or
benefit
information for
any
purpose that
is
not
permitted
by
all
applicable
legal
authorities.
You
may
revoke
your
written
permission
at
any
time,
except
if
VA
has
already
acted
based
on
your
permission.
SPECIFIC
INSTRUCTIONS
Questions
I
-
S
In
this
section,
give
us
your pertinent contact
information
to
include
name,
address,
contact
numbers,
and
e-mail address.
Question
7
Tell
us
the
type of
information
you would
like
VA
to
release to
your
authorized
third
party.
Question
S
This
section
tells
VA
the
duration
of
your
consent.
If
you
do
not
want
your authorization
to be
effective
indefinitely,
tell
us
when
to
stop
releasing
your
personal
benefit
or
claim
information
to
your
authorized
third
party.
Check
the
box
that
applies
and
fill
in
dates,
if
applicable.
Question
10
VA
will
give
your
personal
benefit
or claim
information
to
the
person
or
organization
you
fill
in
here. You
may
only
select
one
person
or
one
organization.
If
you
designate
an
organization,
you
must also
identify
one
or
more
individuals
in
that
organization
to
whom
VA
may
disclose
your
benefit
or claim
information.
This
form
cannot
be used
to
disclose
federal
tax information
to
third
parties.
Question
11
Select
the
security
question
you
would
like
us
to ask
your
designated
third
party
and
provide
the
answer.
This
question
will
be
asked
each
time
your
designated
third
party
contacts our
office.
Where
Do
I
Send
My
Completed
Form?
You can obtain
the
VA
mailing
address
to
send
your
completed,
signed
authorization
by
accessing
our
Internet
website
at
htto:/Mww.va.oovldirectorv
or
in
the
government
pages
of
your
telephone
book
under
“United
States Government,
Veterans.”
You
should
make
a
copy
of
your
signed authorization for
your
records before
mailing
it
to
VA. You
can
only
have
one
active
VA
Form
21-0845
on
file with
VA
at
a
time.
WHAT
IF
I
CHANGE
MY
MIND?
If
you
change
your mind
and
do
not
want
VA
to
give
out
your
personal
benefit
or
claim
information,
you
may
notify
us
in
writing,
or
by
telephone
at
1-800-827-1000
or
electronically
via
the Internet
at
Pttps:/)iris.va.gov.
Upon
notification
from
you
VA
will
no
longer
give
out
benefit
or claim information
(except
for
the information
VA
has
already
given
out
based
on
your
permission).
~A
FORM
MAY2018
—
Page 57
0MB
Approved
No.2900.0736
Respondent
Burden:
5
minutes
Expiration
Dale:
09/301206
Department
of
Veterans
Affairs
(DO
NOT WRITE
N
THIS
SPACE)
(VA
DATE
STAMP)
AUTHORIZATION
TO
DISCLOSE
PERSONAL
INFORMATION
TO
A
THIRD
PARTY
INSTRUCTIONS:
Use
this
form
if
you
want
to
give
lire
Deporiment
of
Veterans
Affairs
permission
lo
release
your
personal
beneficiary
orciaim
information
to
a
third
party.
This
form
may
not
be
executed
by
any
beneficiary
recognized
as
incompelent
far
VA
purposes,
nor
can
VA
accept
this
form from
any
beneficiary
recognized
as
incompetent
for
VA
purposes.
LNAME
OF
VETERAN
(First,
Aliddle
InitiaL
Laso
______________________________________________________
ii
IIIIILIIHEIII
1111111
2.
NAME
OF
BENEFICIARY/CLAIMANTV.I-l0
IS
NOT
THE
VETERAN
(First
Middle
InitiaL
Last)
HI
11111111
HflI
1111
1111111
IH
III
3.
AD0RESS
OF
BENEFICIARY1CLAIMANT
(Nuotber
atari
Street
ori’,,raI,va,tt~
City
or
P.O..
Stole
and
ZIP
C’od4
Number
and
Street
orRuralRoule,P.O.
I I
I
I
I
I
Box
Apt.tUnit
Number
City,
State,
ZIP Code
_________________________________________________________
______________
________________________
endCountry
H1IIIHH1I1H11
IHIImHIHIIIIIFIIIII
4.
VA
FILE
NUMnER
5.
SOCiAL
SECURITY
NUMBER
I I I I
I I
i-rn-i
I
&
CONTACT
INFORMATION
A.
PREFERRED PHONE
NUMBER
B.
PREFERRED
E-MAILADDRESS
(/f
applicable)
C
)
7.
I
(beneliciaryklaimant)
authorize
the
Department
ctVeterans
Affairs
(VA)
to
contact
the
person
or
organ~ation
listed
below
fortha
purposes
of
providing
the
following
information
perlaining
to
my
VA
record.
(Check
any
one
box
below
to
tell
PA
the
specific
benefit
ordain,
info,’mation
you
Iran?
discloset9
Ally
Information
(Go
so
Item
9)
[‘S]
Limited
Information (Go to
heirr
~)
8.
iF
YOU
SELECTED “LIMITED
INFORMATION”.
CHECK
ALL
THAT
APPLY
U
Status
of
pending
claim
or
appeal
Amount
of money
owed
VA
fl
Othor
Q
Current
benetit
and
rate
~
Request
a
benefit
payment
letter
~
Payment history
~J
Change
of
address
or
direct
deposit
9.
IF
YOU SELECTED
‘ANY
INFORMATION’.
THE
TERMS
OF
SUCH
RELEASE
CF
INFORMATION
~.1LL
BE:
U
One
time only
From
the
dale
of
signing
below
until
U
Ongoing
until
written
natlto
Is
givon
tO
VA
to
torrninate
(Specif)’ date
-
month,
doy,
yem)
ID.
VA
IS
AUTHORIZED
TO
DISCLOSE
THE
INFORMATION
AS
SPECIFIED
ABOVE
TO
THE
PERSON
OR
ORGANIZATION
LISTED BELOW.
NOTE:
IF
AUTHORIZATION
IS
FOR
AN
ORGANIZATION,
PLEASE
PROVIDE
THE FIRST
AND
LAST
NAME
OF
THE
ORGANIZATIONS
REPRESENTATIVE.
A,
NAME
OF
PERSON
OR
ORGANIZATION
B.
ADDRESS
OF
PERSON
OR
ORGANIZATION
11.
SPECIFY
THE
SECURITY
OUE5TION
YOU
WANT
USED
b1MEN
VERIFYING
THE IDENTITY
OF
YOUR
DESIGNATED
THIRD
PARTY.
CHECK
ONLY
QN~
SECURITYQUESTION
BOX
IN
hA
AND
PROViDE
THE ANSWER
IN
hIB.
A.
SECURITY QUESTION
B.
ANSWER
[]
The
city
and slate
your
motherwes
born
in
~
The
name
otthe
high
school
you
attended
fl
Yourfirstpefs
name
El
Your
favorite
teaehe?s
name
El
Your
father’s
middle
name
12k
SIGNATURE
(Do
A’OTp;’i;it)
12B.
DATE
SIGNED
PRIVACY ACT
INFORMATION:
VA
will
nec disclose
infannation
collected
on
his
fonn
us
any
sourceotlter
lien
mime has
been
authorized
under
he
Privacy
Act
of
t974
or
ills
38,
Code
of
Federal
Regulations
L576
for
roatiitc
uses
(i.e.,
civil
or
criminal
law
catbrcetnenr,
uengreaaiotsal
communications. rpidesnintogical or
research
studios,
sIte
collectian
at
rnoncy
owed
to
bc
United
Stales,
litigasion
inwltielt
tim
Unlied
Slates
is
a
party
or
has
an
income,
iha
admirialntion
or
VA
programs
mid
delivery
of
VA
benefits,
verilientiaa
ofieieinily
acid
stares,
and
personnel
uthriittistcatioi,
as
identified
its
chic
VA
system
ortccord,,
58VA2I122/28
Compensation,
Pension,
Edseation,
andVocationnl
Rehabihitsation
and
Employment
Records
—
VA,
published
in
else
Fadocat
Reginer.
Yommr
obligation
to
renpoad
is
toltiarary. VA
uses
your
55W
to
identity
yaurclaim
file
Providing
yaur
55W
wilt
help
easme.itier
your
recards
arc
properly
ansociaisd
with
yoar
claim
file,
Diving
us yourSSN
accaunt
infonnation
is
voluntary.
Refltaal
Co
provide
your
55W
by
itaelfwilt
tar
result
in
lie
denial
ot’betaetiia.
The
VA
will
not deny
sas
individual
benefits
for
tefusimtg
to
provide
his
enter
55W
unlesm
rIse
disciasureofihe
55W
is
required
by
Federal
Searuto
oflamv
in
effect
prier
to
January
I,
1975,
and
still
in
efThco.
RESPONDENT
BURDEN:
\Ve
need
ntis
infemsatien
10
releaseyour
private benefit
andlor
claim
informariott
ro
a
designated
third
pany(ies).
The execution
oftlus
form
dres
riot
authorize
mIte
release
afitifontiatian
alhcn
than
that
specifically
described.
The
inrannatien
requested
on
this
rotin
will
authorize
release
arnie
int’onnelien
you
sp:ei~’.
Title
38,
United
States
Cade,
allamvs
nato
ask
torthis
itrfbrritamiotr.
\Vc
estimate
that
you
will
teed
an
average
of’S
ntiaulea
to
review
cite
instructions. md
lie
infonnaiion.
acid
complete
titis
icon. VA
eamtnar
conduct
orspotasnr
collection
oI’infonm:atiatm
unless
a
valid
DM13
control number
is
displayed,
You
are
cot
required
to
respond
ba
collection
ot’infonatatiept
iflhis
number
it
nat
dieplayed,
Valid
0MB
control
numbers
cart
be
located
en
cite
0MB
Internet
Page
ac,sxas’
csjissth,sa”nsehIictdaLERS~Jaiae,
If
desired,
you
can
call
1400-527—1000
Ce
get
inreneatien
on
where
to
tend
eatnerenes
or
smsggcslions
about
ntis
fonn.
VA
FORM
n-I
flOA
SUPERSEDES
VA
FORM 21’D045,
MAY
2010,
WrIICH
MAY2015
~
IMLLNOTBEUSED.
Page 58
INSTRUCTIONS
FOR
MEDICAL
EXPENSE
REPORT
VA
may
be
able
to
pay
you
at
a
higher
rate
if
you
identi~’
expenses
VA
considers
allowable.
Medical
and
dental
expenses
paid
by
you
may
be
deductible
from
the
income
VA
counts
when
determining
your
benefit entitlement.
In
Items
20
and
21
below,
identit’
any
medical
or dental
expenses
that
you
paid
for
a
member
of
your
household
(sell~
spouse,
child,
etc.)
for
which
you
were not
reimbursed.
Below
are
examples
of
expenses
you
should
include,
if
applicable:
•
Hospital
expenses
•
Nursing
home
costs
•
Doctor’s
office
fees
Hearing
aid
costs
•
Dental
fees
‘
Dental
fees
•
Prescription/non-prescription
drug
costs
•
Home
health
service
expenses
•
Vision
care
costs Expenses
related
to
transportation
to
a
hospital,
•
Medical
insurance
pretniums doctor,
or
other
medical
facility
•
Monthly
Medicare
deduction
IMPORTANT
NOTES
•
Do
not
include
any
expenses
for
which
you
were reimbursed.
If
you
receive
reimbursement
after
you
have
filed
this
claim,
promptly
noti&
the
VA
office
handling
your
claim.
•
If
you
are
not
sure
whether
a
particular
expense
can be
allowed,
furnish
a
complete description
of
the
purposes
of
the
payment
We
will
let
you
know
if
an
expense
cannot
be
allowed.
You
may
be
asked
to
veri~’
the
amounts
you actually
paid,
so
keep
all
receipts
or other
documentation
of
payments
for
at
lease
3
years
after
we
make
a
decision
on
your
medical
expense
claim.
If
you
are
unable
to
provide
documentation
of
the
claimed medical
expenses
when
asked
to
do
so
by
VA,
your
benefits
may
be
retroactively
reduced
orterininated.
•
If
more
space
is
needed
to
report
expenses,
attach
a
separate
sheet
of
paper
with
columns corresponding
to
those
on
this
form.
Be
sure
to
write
your
VA
file
number
on
any
attachments.
PRIVACY ACT
NOTICE:
VA
‘viii
not
disclose
information
collected
on
this
form
to
any
source
other
than
what
has
been
authorized
under
the
Privaoy
Actof
197$
orTitle
38,
code
of
Federal
Regulations
1.576
for
routine
uses
(i.e.,
civil
or
criminal
law
enforcement, congressional
communications,
epidetniological
or
research
studies,
the
collection
or
money
owed
to the
United
States,
litigation
in
which
the
United
States
isa
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,
58VA2l122128,
Compensation,
Pension,
Education,
and
Vocational Rehabilitation
Records
-
VA,
and
published
in
the
Federal
Register.
Your
obligation
to
respond
is
required
to
obtain
or
retain
benefits. The
requested
infonnation
is
considered
relevant
and
necessaty
to
determine
maximum
benefits
provided
tinder
law.
VA
uses
your
SSN
to
identi&
your
claim
file.
Providing
your
SSN
will
help
ensure
thotyour
records
are
properly
associated
with
your
claim
file.
Giving
us
your
SaN account
itifonnation
is
voluntary.
Refusal
to
provide
your
SSN
by
ilsel?
‘viii
not
result
in
the
denial
of
benefits.
VA
‘viii
not
deny
an
individual
benefits
ror
refusing
to
provide
his
or
her
SSN
unless
the
disclosure
of
the
SSN
is
required
by
a
Federal
Statute
of
law
in
effect
prior
to
January
l~
1975,
and
still
in
effect.
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.
RESFONDENT
BuRDEN:
We
need
this
information
to
determine
whether
medical
expenses
you
paid may
be
used
to
reduce the
amouttt
of
income
we
count
in
determining
eligibility
to
benefits
(38
U.S.C.
l503).Title3S,
United
Slates
Code,
allowsus
to
ask
forthis
information.
We
estimate that
you
will
need
an
average
of
30
ntinutes
to
review
the
instructions, find
the
information,
and
completc
this
form.
VA
cannot
conductor
sponsor
a
collection
of
infonnation
unless
a
valid
0MB
control
number
is
displayed.
You
are
not
required
to
respond
to
a
collection
of
information
ii
this
number
is
not displayed.
Valid
0MB
control
numbers
can
be
located
an
the
0MB
Internet
Page
at
~vww.reeinfo.novfpuhlic/do/PRAMain.
If
desired,
you
can
call
1-800-827-1000
to get
information
on
where
to
send
comments
or
suggestions about this form.
VA
FORM
supERsEocs
VA
FORM
21P.e416,
OEC
2011.
FEB
2012 21
P—841
6
~MlmcswLLNoTaE
usso.
Page 59
Department
of
Veteran
Services
294
Main
Street
•
Greenfield,
MA
01301
Phone
413-772-~57]
a
Fax413-772-1401
www.ereen
field-ma.
got’
Timothy
Niejadlilc,
Director
Laura
Theme,
Assistant
Mark
Fitzpatrick,
VSO
Brian
Brooks, YSO
UPPER
PIONEER
VALLEY
VETERANS’
SERVICES
DISTRICT
Veteran Resource
and
Referral
Center
located in
Groenfleld, satellite
locations
throughout
tl~
e
titsirict
LISTING
OF
POSSIBLE
MEDICAL
EXPENSES
(~
Abdominal supports
•>
Acupuncture
service
+
Ambulance
hire
+
Anesthetist
(‘
Arch
supports
+
Artificial
limbs
and
teeth
+
Back
supports
+
Braces
•>
Cardiographs
+
Chiropodist
+
Chiropractor
•:~
Convalescent
home
(for
medical
treatment
only)
(~
Crutches
+
Dental
service
(e.g.,
cleaning,
x
ray,
filling
teeth)
+
Dentures
••
Dermatologist
+
Eyeglasses
+
Food
or
beverages
specially
prescribed
by
a
physician
(for
treatment
of
illness,
and
in
addition to, not
as
a
substitute
for.
regular
diet
-
physician’s
statement
needed)
+
Gynecologist
•
Hearing
aids and
batteries
•>
Home
health services
+
Hospital
expenses
+
Insulin
Treatment
+
Insurance
premiums
(for
medical
insurance
only)
+
Invalid
chair
•÷
Lab
tests
+
Lip
reading
lessons
(designed
to
overcome
a
disability)
•t~
Neurologist
(•
Nursing services
(for
medical
care,
including
nurse’s board
paid
by
claimant)
Occupational
therapist
•:~
Ophthalmologist
(t
Optician
+
Optometrist
+
Oral
surgery
+
Osteopath,
licensed
<‘
Pediatrician
+
Physical
examinations
•:•
Physician
+
Physical
therapy
•:~
Podiatrist
+
Prescriptions
and
Drugs
+
Psychiatrist
+
Psychoanalyst
•‘
Psychologist
•:•
Psychotherapy
+
Radium
therapy
+
Sacroiliac
belt
+
Seeing-eye
dog
and
maintenance
+
Speech
therapist
•~
Splints
•:•
Supplementary
medical
insurance
(Part
B)
under
Medicare
+
Surgeon
+
Telephone/teletype
special
communications
equipment
for
the
deaf
•:•
Transportation
expenses
for
medical
purposes (20
cents
per
mile
plus
parking
and
tolls
or
actual
fares
for
taxi,
buses,
etc.)
+
Vaccines
+
Vitamins
prescribed by
a
doctor
(but
not
as
a
food supplement
or
to
preserve
general
health)
Wheelchairs
+
Whirlpool
baths
for
medical
purposes
•+
X
rays
The
Town
of
Greenfield
is
an
Affirmative
AcliowEqual
Opportunity
Employer,
a
designateri
Greci,
Comninnity ant!
a
recipient
of
the
~Leading
by
J.Lewnple”
Award
Page 60
Department
of
Veterans
Affairs
MEDICAL
EXPENSE
REPORT
0MB
Control
No.
2900.0161
Respondent
Burden:
30
minutes
FOR
VA
USE
ONLY
1.
FiRST
NAME
OF
VETERAN
2.
MIDDLE
NAME OF
VETERAN
3.
LAST
NNAE
OF
VETERAN
4.
SUFFIX
NAME
OF
VETERAN
S.
VETERAN’S
SOCIAL SECURITY
NO.
6.
VA
FILE
NUMBER
7.
FIRST
NAME
OF
CLAIMANT
S.
MIDDLE
NAME
OF
CLAIMANT
9.
LAST
NAME
OF
CLAIMANT
10.
SUFFIX
NAME
OF
CLAIMANT
11.
STREETADORESS
OFCLAIMANT
12,
APT.
NO.
13.CITY
14.STATE
l5.ZIP000E
16.
DAYTIME
TELEPHONE
NO. OF
CLAiMANT~ac/adrAreac~efrJ
17.
EVENING TELEPHONE
NO.
OF
CLAIMANTUicAa/&Zr4’aC,:k)
16.
CHANGE
OF
ADDRESS
(C/rack
hu
lath/ran
ml?
19,
E-MAIL
ADDRESS
OF
CLAIMANT
(/fappffcairf~’)
‘rains
/1.15
irdØ5rremfromltze,
cd,irasgfi,rnlslwdø
I~1)
C
20.
ITEMIZATION
OF
EXPENSES
RELATED
TO
TRANSPORTATION
FOR
MEDICAL
PURPOSES
Report
expenses
related
to
transportation
to
a
hospital,
doctor,
or
other
medical
racility
that you
paid between
the
dates
___________________
and
__________________
[lao
dates
appear on
this
line,
refer
to
the
accOlnpanying
letter
or
Eligibility
Verification
Report
for
the
dates
you should
report
medical
expenses.
NOTE:
If
you
claim
miles
traveled
to
a
medical
facility
in
a
personal conveyance
(car,
motorcycle,
other),
VA
will
calculate
the
allowable
expense
amount
based
on the
current
mileage
rate
(41,5
cents
per
niIe~.
B.
TOTAL
ROUNDTRIP
C.
AMOUNT
PAID
BY
YOU
0.
DATE
PAID
E.
FOR
WHOM PAID
A,
MEDICAL
FACILITY
TO
WHICH
MILES
TRAVELED
(Tat/pith/ic
iransporiaiioufares,
(Month/Jay
Year?
(Stj(
spouse.
child?
YOU
TRAVELED
(Persenal
cani’a~’ai,ce
an/i,)
rolls,
parking
/~g5,
ate)
IMPORTANT:
Be
sure
to
sign
this form
ire
Item
22A
on
the
reverse
side.
Unsigned
reports
will
be
returned.
IAFORM
2’IP-8416
FEe
2012
SUPERSEDES
VA
FORM
21P.e41e.
0CC
2011,
W11ICH
WLL
NOT
BE
USED.
(Continued
on
Reve,se,)
Page 61
21.
ITEMIZATION
OF
MEDICAL
EXPENSES
Report
medical
expenses
that
you
paid
between
the
dates and
If
no
dales
appear
on
this
line,
refer
to
the
accompanying
letter
or
Eligibility
Verif1cation
Report
for
the
dates
you should
report
medical
expenses.
A.
MEDICAL
EXPENSE
(P)v~sician
~
B.
AMOUNT
PAID
1
C.
DATE
PAID
0.
NAME
OF
PROVIDER
E.
FOR
WHOM
PAID
Hospital
(‘harges,
E,yeWcsses,
O.~’gcn
BY
YOU
fMonthlflay/Yeai9
(ivwne
of
doctor,
dentist.
Rental
Medical
Inswvnce.
etc.)
hospital.
lab.
etc.)
~‘Sag
spouse.
child.)
MEDICARE (PART
B)
MEDICARE
(PART
0)
PRIVATE
MEDICAL
INSURANCE
CERTIFICATION;
I
have
not
and
will
not
receive
reimbursement
for
these
expenses.
I
certi~’
that
the
above
information
is
true.
22A.
SIGNATURE
OF
CLAIMANT
(DoNOTpni,Q
22B.
DATE
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.
VA
FORM 21P.8416.
FEB
2012
Page 62
CARE PROVIDER CERTIFICATION OF SERVICES (FORM FV13)
Instructions for Filling out this Form
The purpose of this form is to provide the Department of Veterans Affairs (VA) with detailed
information about the types of care support services you (the care provider) are currently
providing the claimant (i.e. a veteran, the veteran’s unhealthy spouse, or the surviving spouse of
a veteran who is applying for a benefits). Please complete pages one and two of this form.
The claimant and the care provider supervisor or facility administrator must sign this form.
VA's Use of the Term "Medical Services"
VA uses the terms "Medical Services" and “Nursing Services” interchangeably. Below is a list of
some Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL).
Generally, services for care and a need for care involving two or more of ADLs
are necessary for
the claimant’s ongoing care costs to be considered unreimbursed medical expenses (UMEs).
Help with getting in and out of bed / transferring (ADL)
Help with dressing (ADL)
Help with ambulating / walking (ADL)
Help with bathing / showering (ADL)
Help with feeding (ADL)
Help with toileting (ADL)
Help with incontinence (ADL)
Help with personal hygiene (ADL)
Help with prosthetic adjustments (ADL)
Close supervision to prevent injury, wandering, or falls (ADL)
Preparing and serving meals (IADL)
Providing room and board (IADL)
Doing housework and laundry (IADL)
Supervising or providing reminders for medication (IADL)
Providing transportation (IADL)
Help with answering the telephone (IADL)
Help with keeping track of money and paying bills (IADL)
Secured living arrangements and emergency pull cords (IADL)
Protected Environment
“Protected Environment” means professional services in a daily living arrangement for adults
who are experiencing a decrease in physical or mental or social functioning and require direct
supervision and support. A person requiring a protected environment could not function by
himself or herself without this need for support. This daily living arrangement can be in a home
or in a facility.
VA often requires a care provider to certify that the claimant is being cared for in a Protected
Environment. Page two of this report will give you the opportunity to provide VA with evidence
that the claimant’s Protected Environment needs are being met. They will use this information to
base a decision on the claimant’s need for care and application for benefits.
Page 63
Line 1. Name of Person Receiving Care Services
This person can either be the veteran or the non-veteran spouse of the veteran. This person can
also be the single surviving spouse of a veteran.
Line 2. Name of Veteran (For VA Purposes)
This must always be the name of the veteran whether the veteran is living or dead.
Line 3. Veteran Social Security Number or VA Case (Claim) Number
This must always be the Social Security Number of the veteran whether living or dead. As a
general rule, with new applications, there is no VA case (claim) number. It would only exist if
the veteran or the surviving spouse had previously made a claim to VA.
Line 9. Name of Care Service Provider
This is the name of the assisted living facility, board and care, adult day, home care company or
private in-home attendant.
Line 10. Complete Address and Phone Number of the Care Service Provider
This is the address and phone number of the assisted living facility, board and care, adult day,
home care company or private in-home attendant. Please know that VA will likely contact you
before they make a decision on the claimant’s application. VA will ask questions about the care
you are providing the claimant and if monthly payments for care have been and will continue to
be made. Generally, a claimant is not eligible for benefits if payments for care are reduced or
cease.
Page 64
CARE PROVIDER CERTIFICATION OF SERVICES - Form FV13
1. Name of Person Receiving Care Services 2. Name of Veteran (For VA Purposes)
3. Veteran Social Security Number
or VA Case Number
4. Address of Person Receiving Care Services
5. City
6. State 7. Zip
8. Phone(s) and email
9. Name of Care Service Provider 10. Complete Address and Phone Number of the Care Service Provider
Check the appropriate box below for the type of service offered by the care provider.
Residential Care Facility
Nursing Home
Adult Foster Care
Assisted Living
Adult Day (Care) Service
Adult Family Home
Professional Home Care Company
Private In-Home Attendant
If care provider provides 24-hour permanent residence for the care recipient, fill in the information below.
Date service started __________________________
Monthly charges including room and board, extras and
care services $_____________________
Monthly charges must be documented by at least one
month's paid services on an invoice marked "paid."
Care provider anticipates the need for services will continue
month-to-month. Yes___ No___
Care provider provides a "protected environment" for the
care recipient. Yes___ No___
If care provider offers assistance during the day at a location other than the care recipient's home, fill in below.
Date service started __________________________
Number of hours per day of service ______________
Number of days per week of service _____________
Care provider anticipates the need for services will
continue month-to-month. Yes___ No___
Monthly charges including meals, site-to-site transportation
and care services $______________________
Monthly charges must be documented by at least one
month's paid services on an invoice marked "paid."
Care provider provides a "protected environment" for the
care recipient. Yes___ No___
If care provider offers assistance in the home of the care recipient or in the home of someone else, fill in below.
Date service started __________________________
Number of hours per day of service ______________
Number of days per week of service _____________
Care provider anticipates the need for services will
continue month-to-month. Yes___ No___
Please attach a copy of the care provider contract.
Monthly charges including meals, transportation,
housework and care services $_____________________
Monthly charges must be documented by at least one
month's paid services on an invoice marked "paid.")
Care provider provides a "protected environment" for the
care recipient. Yes___ No___
SVSA Form FV13, May 2016 Page 1 -- (Form FV 13 Continued on Page 2 on Next Page)
Page 65
Form FV13 - CARE PROVIDER CERTIFICATION OF SERVICES - Page 2
COMPLETE THIS SECTION FOR ASSISTED LIVING, HOME CARE, ADULT DAY CARE, NURSING HOME, IN-HOME ATTENDANT, etc
Please describe briefly the "protected environment" and/or care services being furnished for the care recipient above.
Does the care provider provide "Nursing Services" for the care recipient? Yes ___ No ___
DEFINITION OF NURSING SERVICES
(necessary for allowing deductibility of certain costs)
(M21--1MR, Part V, Subpart iii, Chapter 1, Section G, 43) . . . "Examples of nursing services are assisting an individual
with bathing, dressing, feeding, and other activities of daily living,
" …walking, toileting, hygiene assistance.
CARE PROVIDER -- LINE 9 ABOVE -- OFFERS THE FOLLOWING SERVICES FOR THE CARE RECIPIENT -- LINE 4 ABOVE:
ACTIVITIES OF DAILY LIVING INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Yes No Yes No
Provides help with getting out of bed (ADL) Provides room and board
Provides help with dressing (ADL) Provides shopping services
Provides help with bathing (ADL) Provides emergency response staff
Provides help with ambulating/walking (ADL) Provides supervision and / or reminders for medications
Provides help with toileting (ADL) Provides housework services (cleaning, laundry, etc…)
Provides help with incontinence (ADL) Answers phones and / or keeps track of money and bills
Provides help with feeding (ADL) Provides homemaker services
Provides supervision and properly secured living
arrangements for a protected environment (ADL)
Provides meals because care recipient above is physically
or mentally incapable of preparing his or her own meals
Provides help with personal hygiene (ADL) Provides medical or monitoring alert equipment
Provides for frequent need of adjustment of special
prosthetic or orthopedic devices (ADL)
Providing activities and an environment for necessary
social stimulation
Provides supervision to prevent person from
harming self or wandering (ADL)
Physical security such as room checks, emergency pull
cords, locked and/or monitored exterior doors
Provides supervision to prevent person from
harming others (ADL)
Provides transportation for doctor visits and other vital
medical purposes
Other (ADL): Other (IADL):
This form should be signed by the claimant and a supervisor, administrator, owner or other responsible person with the
care provider. For a personal in-home attendant, the in-home attendant should sign this form.
We, the below signing persons, certify the above information is correct and true to the best of our knowledge.
Care Provider’s Name & Title: ______________________________________
Care Provider 's Signature: ______________________________________
Claimant 's Signature: ___________________________________________
Date Signed:__________________
SVSA Form FV13, May 2016
Page 66
0MB
Control
No
20004075
Respondent
Burden
IS
m~suIos
Department
of
Veterans
Affairs
STATEMENT
IN
SUPPORT
OF
CLAIM
PRIVACY
ACT
INFORMATION;
Tue
“A
~viIl
not
disclose
infonnasion
collected
or,
tub
ronn
to
any
source
other
than
what
hi
bent
ateshoriaod
tinder
rite
Pdvacy
Act
or
1974
erTitlo
30.
Code
ofrednrnl
Rcg.tlaoioras 1.576
forroutine
uses
(i.e.
civil
or
crinainal
law
cntorcatncnt,
congressional
oom,nunbcations,
cpidcuniological
or
research
,tntdica.
clii collection
ormoncy
owed
to
tie
United
Stales.
liti0ntion
in
wI,ielt
die
United
States
is
a
patsy
or
lace
an
interest.
ihe
administration
of
VA
Progn,tnu
asad
delivery
of
VA
hcnefftt.
verification
oridentisy
and
stats’s.
and
personnel
admisisbranon)
as
identified
in
cite
VA
svsictn
or
records,
$&VA2
1/22/28, Cotnpensalio:a.
PoisSon,
Education,
and
Vocational
Relsabiiirntio,t
atad
Etatpioymrnt
Records
—
VA.
published
in
tito
Federal
Register.
Your
obligation
to respond
is
required
In
obtain or
retain
benefit,.
VA
uses
your
SSN
to
identi5’
your
chin’
file.
Providing
your
SSN
tvill
utsip
essttm
hat
your
records
are
properly
associated
whit
yo,trelatn,
file.
Giving
cr5
your
SSN account
infonaasion
is
voluntary. Reflinal
to
provide
your
SSN
by
htselfwill
not
insult in
site
denial
arbenens.
The
VA
will
not
deny
an
individual
bettnflts
forrcfiusino
to
provide
his
or
her
55W
unlcas
tic
disclosure
ofthte
SSN
is
required
by
Federal Statute
oflaw
in
oftbcn
priorno
.Januaiy
I,
1975.
stud
still
iii effect.
TOte
requested
informution
is
considrred
reievm,t
and
tiecessucy
to
datonnina
,,aanimu,a
bcttcflus
under
tIle
tan.
lisa
etupotases yore
nubmis
arc
considered contidetatiat
(38
U.S.C.
SlOt).
lnfonaaatio,u
statunittod
is
subject
to veritbceniert
through
co,aptttcr
matching
programs
with
enter
agencies.
RESPONDENT BURDEN:
\Vc
need
Isis
information
to
obtain
evidence
in
stppon
ofynur
claim
rorbotefits
(38
U.S.C
$OtØt)
and
(b3).
Title
38.
United
States
Code,
allows
‘Ia
to
ask
for
iltis
infonytahion.
We
eutitnale
dIal
you
wilt
need
eta
average
of
IS
minutes
to
rovisuv
thu
instnsctionn,
fled
the
infonnatton.
ansI
coinplcto
this
fonn.
VA
eatt,tni
conduct
or
sponsor
a
collection
of
information
unless
atlid 0MB
control
number
is
displayed.
You
arc not
required
to
respond
to
a
cottecnioa
or,nfornaation
iftMs
number
is
net
displayed.
Valid
0MB
control
nrttnbctscan
be
loaned
on
llte
0MB
Internee
Page
at
uc.rssd’o,Rox(lgcittte1nl.o/fR~Mtuo.
lfdcaired,
you
coo
call
t-800-827—t000
logo’
information
on
,vttae
to send
comments
or
tuggeations
about
this
fonn.
FIRST
NPME-
MIDDLE
NAME
-
LAST
NAME
OF
VETERAN
(Fype
or
pu/ni,)
SOCIAL
SECURITY
NO.
VA
FILE
NO.
CICsS
-
Thu following
slalement
is
made
in
canneelion
witha
claim for
benefits
in
the
ease
of
the
above-named veleran:
I
CERTIFY
THAT
the
slolemenls
on
this
form
ore rue
and
correct
to
the
best
of
my knowledge
and
belien
SIGNATURE
DATE
SIGNED
ADDRESS
TELEPHONE
NUMBERS
(htc/t,s?o
,lrrgCcd4
DAYTIME EVENING
PENALTY:
The
law
provides
severe
penalties
which
inelttde
fine
or
imprisonment,
or
hod,,
for
the
willful
submission
ofany
statement
or
evidence
ofa
material
fact.
knowing
it
to
be
false.
VA
FORM
‘I
Ad
‘ao
EXISTING
STOCKS
OF
VA
FORM
21-4138,
AUG
2004.
AUG
2011
‘“°“
WLL
BE
USED
CONTINUE
ON
REVERSE
Page 67
INSTRUCTIONS:
For
free
help
in
completing
this
form,
call
VA
loll-free
at
1-800-827-WOO.
(Hearing
Impaired
TDD
line
1-800-829-4833.)
IA.
NAME
OF
NURSING
HOME
lB.
ADDRESS
OF NURSING
HOME
2.
ADDRESS
OF
VA
REGIONAL
OFFICE
3.
FIRST
NAME
-
MIDDLE INITIAL-
LAST NAME
OF
CLAIMANT
4.
SOCIAL SECURITY
NUMBER
5.
VA
FILE NUMBER
SECTION
II
-
NURSING
HOME
INFORMATION
(To
be
completed
by
a
Nursing
Home
Official)
6.
DATE
ADMITTED
TO
NURSING HOME
(Months
Day,
Yea’)
7.
DATE
MEDICAID
BEGAN
(Month,
Day,
Veat)
8.
AMOUNT
PATIENT
IS
RESPONSIBLE
FOR OUT
OF
POCKET
S
9.1
CERTIFY
THAT
THE
CLAIMANT
IS
A
PATIENT
IN
THIS
FACILITY BECAUSE
OP
MENTAL
OR
PHYSICAL DISABILITY
AND
IS
RECEIVING:
(Check
one)
~
SKILLED NURSING CARE
~
INTERMEDIATE
NURSING CARE
IC.
NURSING HOME OFFICIAL’S
NAME
(Fi;’s(&
Last)
(Please
print)
II.
NURSING
HOME
OFFICIAUS
TITLE
(Please
print)
12.
NURSING
HOME
OFFICIAL’S OFFICE
TELEPHONE
NUMBER
(Include
Area
C’odej
13A.
SIGNATURE OF
NURSING
HOME
OFFiCIAL
135.
DATE
SIGNED
PRIVACY ACT
NOTICE:
The
VA
cvii
not
disclose
information
collected
on
this
form
to
any source
other
than
what
has
been
aulhorized
under
the
Privacy
Act
of
1974
or
Title
5,
Code
of
Federal
Regulations
1.526
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,
58VA2
1/22128
Compensation,
Pension,
Education,
and
Vocational Rehabilitation
and
Employment
Records
-
VA,
published
in the
Federal
Register.
While
you
are
not
required
to
respond,
your
cooperation
In
providing
this
relevant
and
necessary
inf’onnation
will
help
us
determine
the
claimant’s
maximum
benefit entitlement
under
the
law.
Information
that you
furnish
may
be
utilized
in
computer matching
programs
with
other
Federal
or
state
agencies
for
the
purpose
of
determmmg
the claimant’s
eli~biIity
to
receive
VA
benefits,
as
well
as
to
collect
any
amount
owed
to
the
United
States by
virtue
of
the
claimant’s
participation
in
any
benetit
program
administered
by
the
Department
of
Veterans
Affairs.
RESPONDENT
BURDEN:
We
need
tins
information
to
determine
eligibility
for
benefits
and
the
proper
rate
of
payment
(38
U.S.C.
5503,
38
U.S.C.
1115
(fl(S)),
38
U.S.C.
1311(c), 38
U.S.C.
1315(h)).
Title
38,
Unite&States
Code,
allows
usto
ask
for
this
information.
We
estimate
thatyou
will
need
an
average
of
10
minutes
to
review
the
instructions,
find
the
information
and
complete
this
form.
VA
cannot
conduct
or
sponsor
a
collection
or
information
unless
a
valid
0MB
control
number
is
displayed.
You
are
not
required
to
respond
to
a
collection
of
information
if
this
number
is
not
displayed.
Valid
0MB
control
numbers
can
be
located
on
the
0MB
Internet
Page at
ww~v.whitehnusesovlomb/libmrvJOMSlNV,VA.EPA.html1tVA.
lfyou
desire,
you
can
call
1-800-827-1000
to get
information
on where
to send
comments
or
suggestions
about
this
form.
SUPERSEDES
VA
FORM
2~-O775,
NtAR
20t4.
~ICH
tAtLL
NOT
BE
U550.
Department
of
Veterans
Affairs
REQUEST
FOR
NURSING
HOME INFORMATION
IN
CONNECTION
WITH
CLAIM
FORAID
AND
ATTENDANCE
0MB
Approvcd
No:
29t0-0552
RE5PONDENT
BURDEN:
10
Minuics
VA DATE
STAMP
(Do
Not
Write
In
This
Space)
Section
I
-
IDENTIFICATION
INFORMATION
MAR10
21-0779
Page 68
~/%
Department
of
~
Veterans
Affairs
INCOME
AND
ASSET
STATEMENT
IN
SUPPORT
OF
CLAIM
FOR
PENSION
OR
PARENT’S DEPENDENCY
AND
INDEMNITY
COMPENSATION
(DIG)
(Attachment
to VA
Forms
21P-527,
21P-527EZ,
21P-534, 21P-534EZ,
and
21
-526)
IMPORTANT:
This
is
not
a
stand-alone
form. Only
complete
this
attachment
if
you
are
directed
to
do
so
when you
complete
one
of
the
following:
(I)
Section
VI
on
VA
Form
2lP-527
or
Section
VIII
on
VA
Form
21P-527EZ.
(2)
Section
\~1I
on
VA
Form
21P-534
or
Sectioti
VIII
on
VA
Form
21P-534EZ.
(3)
Section
VIII
on
VA
Form
2
1-526.
VETERAN/CLAIMANT
PERSONAL
INFORMATION
I.
VETERAN’S
NAME
(Last,
First,
Middle)
2,
VETERAN’S
SOCIAL SECURITY
NUMBER
3.
VETERAN’S
FILE
NUMBER
(If
known)
4.
CLAIMANT’S
NAME
(Last,
First,
Middle)
5.
CLAIMANTS
SOCIAL SECURITY NUMBER
6.
CLAIMANT’S
TELEPHONE
NUMBER
7.
TYPE
OF
CLAIMANT
(Check
only
one
box)
D
VETERAN
SURVIVING SPOUSE
H
SURVIVING
CHILD
H
PARENT
IMPORTANT
JNFORMATJON
FOR
CLAIMANTS
NOTE
-
The term
“assets”
means
the
fair
market value
of
all
property
that
an
individual
owns,
including
all
real
and
personal
property(excluding
the
value
of
your
or
your
dependent’s
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
iu
excess
of
being suitable
and
consistent
with
a
reasonable mode
of
life.
If
you
are
a
Veteran,
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
or
children
(sinless
you
do
not
have
custody*
and
you
do
not
contribute
to
your
child’s
or
children’s support)
If
you
are
a
Surviving
Spouse,
you must report
income
and
assets
for:
•
yourself
•
any
child
of
the
veteran
who
is
in
your
custody*
If
you
are
a
Surviving
Child
or
the
Custodian
of
a
Surviving Child,
you must
report income
and
assets
for
the:
•
child
child’s
custodian
(unless the
child’s
custodian
is
an
institution)
•
custodian’s
spouse
If
you
are
a
Parent,
you must
report
income”’
for:
yourself
•
your
spouse
(even
if
your
spouse
is
the
veteran’s
otlierparent.
If
your
spouse
is
the
veteran’s
other
parent,
you
must
boll,
file
claims)
*child
custody
for
pension
purposes
is
defined
in
38
C.F,R,
§
3.57(d),
A
natural
or
adoptive
parent
has
custody
of
a
child
unless
custody
is
legal]y
removed.
For
pension
purposes,
a
child
‘vho
has
attained
age
18
remains
in
the
custody
of
the
person
who
had
custody before
the
child
turned
age
1
8
unless
custody
is
legally
removed.
**
Parent’s
DIC
claimants
do
not
need
to
report
orproi’ide
documentation
of
their
assets,
NOTICE
IMPORTANT:
VA will
compare
the
information
you
report
on
this form to
Internal
Revenue
Service
(IRS)
and
Social
Security
Administration
(SSA)
records
to
verify
your income
for
the
past
three
tax
years
for
which
information
is
available. Information from
the
IRS
or
SSA
that
conflicts
with the
income information
you
provide
with
your
application
may delay
your
claim
and/or
reduce
your
benefIt
amount.
PRIVACY
ACT
NoTIcE:
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, epidemictogicat
or
research
studies,
the
collection
of
money
owed
to
the
United
States,
litigation
in
which
the
united
Stales
is
a
party or
has
en
interest,
the
administration
of
VA
programs
and
defvery
of
VA
benefits.
verification
of
identity
and status,
end
personnel
administration)
as
identified
in
the VA
system
of
records,
58VA21122128.
compensation.
Pension,
Educaton.
and
Vocational Rehabilitation
Records.
VA.
published
ri
the
Federal
Register.
Your obligation
to
respond
is
required
to
obtain
or
retain
benefits.
The
requested information
is
considered retevant
and
necessary
to
determine maximum
benefits provided
under
the law,
Giving
us
your
5511
account
information
is
voluntary.
Refusal
to
provide your
SSN
by
teat
wit
not
result
in
the
denial
of
benefits,
VA
will not
deny
an
individual
benetts
for
refusing
to
provide
his
or
her
SSN unless
the
disclosure
or the
SSN
ts
required
by
a
Federal
Statute
of
law
in
effect
prior
to
January
1,
1975,
and
still
in
effect. The
responses
you
submit
are
considered confidential
(38
U.S.C.
5701). Information
submitted
is
subiect
to
verification
through
computer
matching
programs
with
other
agencies.
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
v,itl
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
0MB
control
number
is
displayed.
You
are
not
required
to
respond
to
a
cotleotion
of
information
if
this
number
is
not
displayed.
Valid
0MB
control
numbers
can
be
located
on
the
0MB
lntemet
Page
ot:
ww.y•reginfq.goy1pstht[c]~oI
?BAMatn.
If
desired,
you
can
call
1.800-827-1000
to
get
information
on
where
to
send
comments
or
suggestions
about
this
romi.
~iA
FORM
21
P-09B9,
OCT 2018
Page
1
Page 69
0MB
Control
No.
2900-0829
Respondent
Burden:
25
minutes
Expiration
Date:
10/31/2021
SECTION
I:
RETIREMENT
INCOME
AND DISTRIBUTIONS (If
additional
space
is
needed
attach
a
separate
sheet)
INCOME
AND
ASSET STATEMENT
IN
SUPPORT
OF
CLAIM
FOR
PENSION OR
PARENTS’
DEPENDENCY
AND
INDEMNITY
COMPENSATION
(DIC)
(Attachment
to
VA
Forms
21
P-
527,
21
P-527EZ,
21
P-534,
21
P-534EZ,
and
21-526)
1.
ARE YOU
OR
YOUR
DEPENDENTS
RECEIVING
OR
EXPECTING
TO
RECEIVE
ANY INCOME
IN
THE
NEXT
12
MONTHS INCLUDING,
BUT
NOT
LIMITED
TO,
DISTRIBUTIONS
FROM
A
RETIREMENT
PLAN, SUCH
AS:
Military
Retirement
Civil
Service
Retiremenl
•
IRA
•
SEP
•
Qualified Plans
•
Pensions
Annuities
Black Lung
~
YES
NO
(If
“No,
skip
to
Section
II)
C.
WHAT
IS
YOUR CURRENT
D.
WHAT
IS
THE
TOTAL
A.
INCOME
RECIPIENT
B.
WHO
IS
THE
INCOME
PAYER?
ANDIOR EXPECTED
INCOME?
CASH
VALUE
OF
THE
(Veteran,
Spouse.
Child,
(Name
of
business,
financial
(Provide
documentation
of current
income
and
ASSET
Parent,
Custodian,
etc.)
institution,
etc.)
expected
income
changes)
ASSOCIATED
WITH
THIS
INCOME?
(Provide
documentation
of
assets)
CURRENT
MONTHLY
$
GROSS
INCOME
DO
YOU
EXPECTTHIS
INCOME
TO
CHANGE
IN
THE
YES
NO
NEXT12
MONTHS?
DATE INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
$
CURRENT
MONTHLY
GROSS INCOME
$
DO
YOU
EXPECT
THIS
INCOME
D
YES
NO
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
DATE INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
$
CURRENT MONTHLY
GROSS
INCOME
$
DO
YOU
EXPECT
THIS
INCOME
TO
CHANGE
IN
THE
D
YES
NO
NEXT
12
MONTHS?
DATE INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
$
CURRENT MONTHLY
$
GROSS
INCOME
DO
YOU
EXPECTTHIS
INCOME
TOCHANGE
IN
THE
fl
YES
UNO
NEXT
12
MONTHS?
DATE
INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
$
~AFORM
21P-0969
OCT
2018
Page
2
Page 70
SECTION
II
-
UNEMPLOYMENT
INCOME
(If
additional
space
is
needed
attach
a
separate
sheet)
2.
ARE
YOU
OR
YOUR DEPENDENTS RECEIVING
OR
EXPECTING
TO
RECEIVE
UNEMPLOYMENT
INCOME
IN
THE
NEXT
12
MONTHS?
D
YES
D
NO
(Ir”No,’
skip
to
Section
III)
B.
WHAT
IS
YOUR
OR
YOUR
DEPENDENTS CURRENT
A.
INCOME
RECIPIENT
AND/OR
EXPECTED
UNEMPLOYMENT
INCOME?
(Veteran,
Spouse,
Child,
Parent,
Custodian,
etc.)
(Provide documentation
of current
Income
and
expected
income
changes)
CURRENT
MONTHLY
$
GROSS INCOME
DO
YOU
EXPECT
THIS
INCOME
TO
CHANGE
IN
THE NEXT
12
MONTHS?
D
YES
NO
DATE
INCOME
WILL
CHANGE AND EXPECTED
INCOME
AMOUNT
CURRENT MONTHLY
GROSS
INCOME
$
DO
YOU
EXPECT
THIS INCOME
TO
CHANGE
IN
THE NEXT
12
MONTHS?
YES
NO
DATE INCOME
WILL
CHANGE AND
EXPECTED
$
INCOME
AMOUNT
CURRENT
MONTHLY
GROSS
INCOME
$
DO
YOU
EXPECT
THIS INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
YES
D
NO
DATE
INCOME
WILL
CHANGE
AND
EXPECTED
$
INCOME
AMOUNT
CURRENT MONTHLY
$
GROSS
INCOME
DO
YOU
EXPECT
THIS
INCOME
TOCHANGEINTHENEXT
YES
UNO
12
MONTHS?
DATE
INCOME
WILL
CHANGE AND EXPECTED
$
INCOME
AMOUNT
VA
FORM
21P-0969,
OCT 2018
Page
3
Page 71
SECTION
III
-
SAVINGS BONDS
(If
additional
space
is
needed attach
a
separate
sheet)
3.
DO
YOU
OR
YOUR
DEPENDENTS
OWN
A
SAVINGS
BOND
OR
RECEIVE
OR
EXPECT
TO RECEIVE
INTEREST
FROM
A
SAVINGS
BOND
WITHIN
THE
NEXT
12
MONTHS?
D
YES
NO (If “No, skip
to
Section
IV)
C.
WHAT
IS
THE
CURRENT
A.
WHO
OWNS THE
SAVINGS BOND?
B.
WHAT
IS
YOUR
OR
YOUR
DEPENDENTS
CURRENT
AND/OR
FACE
VALUE
EXPECTED
ANNUAL
INCOME
(interest
earned)?
OF
THE
(Veteran, Spouse,
Child, Parent, (Attach
a
copy
of
the
savings
bond)
SAVINGS
BOND?
Custodian,
etc.)
WHAT
IS
THE
GROSS
ANNUAL
S
INCOME?
$
DO
YOU
EXPECT
THIS
INCOME
TO
~
YES
NO
CHANGE
IN
THE
NEXT
12
MONTHS?
DATE
INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
S
WHAT
IS
THE
GROSS
ANNUAL
S
INCOME?
S
DO
YOU
EXPECT
THIS
INCOME
TO
fl
YES
NO
CHANGE
IN
THE
NEXT
12
MONTHS?
DATE
INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
S
WHAT
5
THE
GROSS ANNUAL
$
INCOME?
DO
YOU
EXPECT
THIS
INCOME
TO
fl
YES
NO
$
CHANGE
IN
THE
NEXT
12
MONTHS?
DATE
INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
S
WHAT
IS
THE GROSS
ANNUAL
$
INCOME?
DO
YOU
EXPECT
THIS
INCOME
TO
U
YES
NO
$
CHANGE
IN
THE NEXT
~2
MONTHS?
DATE
INCOME
WILL CHANGE AND EXPECTED
INCOME
AMOUNT
$
VA
FORM
21P-0969,
OCT 2018
I~age
4
Page 72
4.
ARE
YOU
OR
YOUR DEPENDENTS RECEIVING
OR
EXPECTING
TO
RECEIVE. INCOME FROM
RENTAL
PROPERTY,
FARM
OR
BUSINESS
WITHIN
THE
NEXT
SECTION
IV
-
RENTAL
PROPERTY,
FARM
OR
BUSINESS
INCOME
(If
additional
space
is
needed
attach
a
separate
sheet)
12
MONTHS?
YES
NO (If
‘No,’
skip
to
Section
V)
B.
WHAT
IS
YOUR
OR
YOUR
DEPENEDENTS CURRENT
OR
A.
INCOME
RECIPIENT
EXPECTED
INCOME
0.
WHAT
IS
THE
VALUE
OF
YOUR
(Veteran, Spouse,
Child,
FROM
THIS
SOURCE?
C.
WHAT
KIND
OF
INCOME PORTION
OF
THE
PROPERTY,
FARM,
Parent,
(Provide
documentation
of current
income
IS
THIS?
OR
BUSINESS?
Custodian,
etc.)
and
(Check
applicable
box)
(Note:
Subtract
the
amount
of Mortgages
or
expected
income changes)
other
encumbrances
specific
to
the
property.
Provide
available
documentation)
CURRENT
MONTHLY
GROSS INCOME
$
r’~
Farm
.
Submit
a
completed
DO
YOU
EXPECT
THIS
INCOME
TO
Li
VA
Form
21P-4165
with
this
application
CHANGE
IN
THE
NEXT
12
MONTHS?
r’,
Rental
Property
.
Submit
a
completed
fl
YES
NO
U
VA
Form
21P’418S with
this
application
DATE
INCOME
Business-
Submit
e
completed
WILL CHANGE
AND
EXPECTED
D
VA
Form
21P4185
with
this
application
INCOME
AMOUNT
S
CURRENT MONTHLY
GROSS
INCOME
$
ri
Farm
-
Submit
a
completed
.___.VA
Form
21P.416S
with
this
applicelion
DO
YOU
EXPECT
THIS INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
Rental
Property
-
Submit
a
completed
~
VA
Form
21P-4185
with
this
application
D
YES
NO
Business
-
Submit
a
completed
DATE
INCOME
E
VA
Form
21
P.4185
with
this
application
WILL
CHANGEAND
EXPECTED
INCOME
AMOUNT
S
CURRENT
MONTHLY
GROSS
INCOME
5
r~
Farm
-
Submit
a
completed
DO
YOU
EXPECT
THIS
INCOME
TO
Li
VA
Form
21P-4165
with
this
application
CHANGE
IN
THE
NEXT
12
MONTHS?
r-t
Rental
Property~
Submit
a
completed
L_i
VA
Form
21
P-4185
with
this
application
~
YES
NO
DATE
INCOME
Bustrtess
Submit
a
completed
WILL CHANGE
AND
EXPECTED
VA
Form
21
P4185
with
this
application
INCOME
AMOUNT
S
CURRENT MONTHLY
GROSS
INCOME
$
DO
YOU
EXPECT
THIS
INCOME
TO
ri
Farm.
Submit
a
completed
CHANGE
IN
THE
NEXT
12
MONTHS?
U_I
VA
Form
21P4165
with
this
application
r’,
Rental
Property.
Submit
a
completed
~
YES
NO
L_J
VA
Form
21P-4185
with
this
application
DATE
INCOME
WILL
CHANGE
AND
EXPECTED
r”l
Business.
Submit
a
completed
INCOME
AMOUNT
U
VA
Form
21P-41e5
with
this
application
$
VA
FORM
21P-0969,
OCT 2018
Page
5
Page 73
SECTION
V
-
INTEREST,
ROYALTIES,
AND
DIVIDENDS
(If
additional
space
is needed
attach
a
separate
sheet)
5.
ARE
YOU
OR
YOUR
DEPENDENTS RECEIVING
OR
EXPECTING
TO
RECEIVE,
INTEREST,
DIVIDENDS,
OR
ROYALTIES
WITHIN
THE
NEXT
12
MONTHS?
YES
NO
(If
‘No,”
skip
to
Seclion VI)
IMPORTANT;
Do
not
report income
you
hove
already reported
in
Section
III
(Savings
Bonds)
or Section
IV
(Rental
Property. Farm
or Business
Income).
A.
INCOME
RECIPIENT
B.
WHO
IS
THE
INCOME
PAYER?
C.
WHAT
IS
YOUR
OR
YOUR DEPENDENTS
D.
WHAT
IS
THE
TOTAL
CASH
(Veteran,
Spouse,
Child,
(Name
of
business,
CURRENT
ANDIOR
EXPECTED
INCOME?
VALUE
OF
THE
ASSET
Parent,
Custodian,
etc.)
financial
institution.
etc.) (Provide
documentation
of
current
income
and
ASSOCIATED
WITH THIS
expected income
changes) INCOME?
(Provide
documentation
of
assets)
CURRENT MONTHLY
GROSS
INCOME
S
DO
YOU
EXPECT
THIS
INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
~
YES
DN0
DATE INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
$
CURRENT MONTHLY
GROSS INCOME
$
DO
YOU
EXPECTTHIS
INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
D
YES
ENO
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME
AMOUNT
S
CURRENT
MONTHLY
GROSS
INCOME
$
DO
YOU
EXPECT
THIS INCOME
TO CHANGE
IN
THE
NEXT
12
MONTHS?
D
YES
E
NO
DATE INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
S
CURRENT
MONTHLY
GROSS
INCOME
DO
YOU
EXPECT
THIS
INCOME
TO
CHANGE
IN
THE NEXT
12
MONTHS?
~
YES
DNO
DATE
INCOME
WILL
CHANGE
AND
EXPECTED
INCOME
AMOUNT
S
VA
FORM
21P-0959,
OCT 2018
Page
6
Page 74
SECTION
VI
-
WAGES
-
INCLUDING
SELF-EMPLOYMENT
(if
additional
space
is
needed attach
a
separate
sheet)
6.
ARE YOU
OR
YOUR
DEPENDENTS
RECEIVING
WAGES
OR
EXPECTING
TO
RECEIVE WAGES WITHIN
THE
NEXT
12
MONTHS?
flYES
~
NO
(If”No,”
skip
to
Section
VII)
A.
WAGE RECIPIENT
B.
WHAT ARE
YOUR
OR
YOUR
DEPENDENTS
CURRENT
WAGES
(Veteran,
Spouse,
Child, Parent,
ANDIOR
EXPECTED
WAGES?
Custodian,
etc.)
(Provide
documentation
of
current
wages
and
expected
wage changes)
CURRENT
MONTHLY
GROSS WAGE
S
DO
YOU
EXPECT
THIS
WAGE
INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
YES
ENO
DATE
WAGE
INCOME
WILL
CHANGE
AND
EXPECTED
WAGE
AMOUNT
S
CURRENT
MONTHLY
GROSS
WAGE
DO
YOU
EXPECT THIS
WAGE
INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
YES
DNO
DATE
WAGE
INCOME
WILL
CHANGE
AND
EXPECTED
WAGE
AMOUNT
S
CURRENT MONTHLY
GROSS
WAGE
S
DO
YOU
EXPECT
THIS
WAGE
INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
YES
NO
DATE
WAGE
INCOME
WILL
CHANGE
AND
EXPECTED
WAGE
AMOUNT
S
CURRENT
MONTHLY
GROSS
WAGE
$
DO
YOU
EXPECT THIS
WAGE
INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
YES
NO
DATE
WAGE
WILL
CHANGE
AND
EXPECTED
WAGE AMOUNT
$
VA
FORM
21P-0969,
OCT
2018
Page
7
Page 75
SECTION
VII
-
DISCONTINUED
INCOME
IN
THE
PRIOR
TAX
YEAR
(If
additional
space
is
needed aftach
a
separate
sheet)
7,
DID
YOU
OIR
YOUR
DEPENDENTS
RECEIVE
INCOME
LAST
YEAR
THAT
Is
NO
LONGER
BEING
RECEIVED
OR
WAS
A
ONE-TIME
PAYMENT?
D
YES
EEl
NO
(If
‘No,”
skip
to
Section
VIII)
C.
WHAT
WAS
THE
GROSS
D.
WHEN
DID
THE
A.
INCOME
RECIPIENT
B.
WHO
WAS
THE INCOME
PAYER?
ANNUAL
AMOUNT
INCOME
STOP?
(Veteran,
Spouse,
Child, Parent,
Custodian,
etc.)
(Name
of
business, financial institution, etc.) REPORTED
TO THE
IRS?
(MM,DD,YYYY)
$
$
S
S
VA
FORM
21P-0969,
OCT2018
PageS
Page 76
NOTE:
Parent’s
DIG
Claimants
Only
-
You
do
not
have
to
complete Sections
VIII
thru
XI.
Return
to
the
application form.
Your
certification,
signature
and
date
on
the
application
form
applies
to
this
attachment.
Pension
Claimants
-
Continue
to
complete
the
attachment.
SECTION
VIII
-
ASSETS
PREVIOUSLY
NOT
REPORTED
(If
additional
space
is
needed
attach
a
separate
sheet)
B.
DO
YOU
OR
YOUR
DEPENDENTS
HAVE
ASSETS
NOTALREADY
REPORTED,
SUCH
AS
NON-INTEREST-BEARING ACCOUNTS,
CASH,
STOCKS,
BONDS,
OR
REAL
ESTATE?
~
YES
fl
NO
(If_“No,”_skio_to_Section_IX)
B.
WHAT
IS
THE
CURRENT CASK
VALUE
C.
AMOUNT
OWED
ON
THE
ASSET
OR
A.
ASSET
OWNER
OF
THE
ASSET? AMOUNT
MORTGAGED
OR
OTHERWISE
(Veteran,
Spouse,
Child,
Parent,
(Provide
a
bank
or
other
official
statement
showing
ENCUMBERED?
Custodial,
etc.)
the
Current
value.
Do
not
report
assets
you
have
already
(Provide documentation
of
mortgages or
other
reoorted
in
Sections
I
throuoh
VIII
encumbrances)
$
S
S
S
S
5
S
S
SECTION
IX
-
ASSET TRANSFERS
(If
additional
space
is needed
attach
a
separate
sheet)
9.
IN
THE CURRENT YEAR
AND/OR PRIOR
3
TAX
YEARS,
DID
YOU OR
YOUR
DEPENDENTS
SELL,
CONVEY,
TRADE,
OR
GIVE
AWAY
ASSETS?
D
YES
D
NO
(If
“No,”
skip to
Section
X)
A.
WHO
OWNED
THE
ASSET?
B.
HOW
WAS THE
C.
WHO
DID
YOU
D.
DETAILS
OF
THE
ASSET
TRANSFER
(Veteran,
Spouse,
Child,
Parent,
ASSET TRANSFERRED?
TRANSFER
(Provide
documentation of
the
transfer,
A
transfer for
tess
than
fair
Custodian,
etc.) THE
ASSET
TO?
market value
means
you
disposed
of
an
asset
for
less
than
the
asset
was worth)
D
SOLD
Name:
Was
the
asset
transferred
for less than
fair market value?
D
Yes
No
fl
CONVEYED
Was
an
asset
reported
to
the
IRS
sold?
D
GAVEAWAY
D
Yes
D
TRADED
What
was the original
purchase
price?_________________________
fl
OTHER
(Explain below)
Relationship:
What
was the sale
price?_______________________
What
date
was
the
asset
sold?
(MM,00,YYW)___________
What
was
the gain
(capital
gain, etc.)?
Was
the
asset transferred
for less than fair
market value?
~
SOLD Name:
Yes
No
~
CONVEYED
Was
an
asset reported
to
the
IRS
sold?
D
GAVEAWAY
Yes
No
~J
TRADED
What
was
the
original
purchase
price?_______________________
~
OTHER
(Explain
below)
Relationship:
What
was
the
sale
price?_______________________
What
date
was the
asset
sold?
(MM,DD.YYYY)____________
,
What
was
the gain
(capital
gain,
etc.)?_________________________
VA
FORM
21P-0969. OCT
2018
Page
9
Page 77
SECTION
IX:
ASSET
TRANSFERS
(Continued)
A.
WHO OWNED
THE
ASSET?
B.
HOW
WAS
THE
C.
WHO
DID
YOU
D.
DETAILS
OF
THE
ASSET
TRANSFER
(Veteran.
Spouse.
ChHd.
ASSET
TRANSFERRED?
TRANSFER
(Provide
documentation
of the
transfer.
A
transfer
for
less
than
fair
Parent,
Custodian,
etc.)
THE
ASSET
TO?
market value
means
you
disposed
of
an
asset
for
less
than the
asset
was worth)
~
SOLO
Was
the
asset
transferred for
less than
fair market
value?
~
CONVEYED
Name:
El
Yes
El
No
Was
an
asset
that was
reported
to the
IRS
sold?
El
GAVEAWAY
El
Yes
ElNo
~
TRADED
What
was
the
original purchase
price?_________________________
~J
OTHER
(Explain
below)
Relationship:
What
was
the
sale
price?_________________________
What
date
was
the
asset
sold?
(MM
DD,YYVY)___________
What
was
the gain
(capital
gain,
etc.)?_______________________
El
SOLD
Was
the
asset
transferred
for
less than
fair market value?
Name:
Yes
No
El
CONVEYED
Was
an
asset
that
was
reported
to
the
IRS
sold?
~
GAVEAWAY
El
Yes
ElNo
El
TRADED
What
was
the
original
purchase
price?_________________________
~
OTHER
(Explain below)
Relationship:
What
was the sale price?_______________________
What
date
was
the
asset
sold?
(MM
,00,YYYY)____________
What
was the gain
(capital
gain, etc.)?_______________________
SECTION
X:
ANNUITIES
AND
TRUSTS
(Attach
a
separate sheet
if
more
than
one
annuity
or
trust
is
involved)
bA.
IN
THE
CURRENT YEAR
OR
THE
PRIOR
THREE
TAX YEARS,
DID
YOU
OR
YOUR
DEPENDENTS
TRANSFER
ANY
ASSETS
TO A
TRUST
OR
PURCHASE
AN
ANNUITY?
El
Yes No
(If
“No,”
skip to
Section
XI)
lOB.
WHAT
WAS THE
MARKET VALUE
OF
THE ASSET
AT
THE TIME
OF
TRANSFER
OR
ANNUITY
PURCHASE?
$
bC.
WHAT
WAS THE DATE THE
ASSET
WAS
TRANSFERRED?
(MM.DD.YYYY)
1OD.
DID
YOU
PURCHASE
AN
ANNUITY
WITH THE
ASSETS?
bE.
PROVIDE
DATE
OF
PURCHASE
I OF.
PROVIDE
NAME
OF
PERSON
THE
ASSET
WAS
PURCHASED
FROM
(First-Midd~-Last)
El
Yes
El
No
(If”Yes,’
complete
Items
ICE through
lOG)
10G.
PROVIDE
TYPE
OF
ANNUITY PURCHASED
(Give
details and
attach
documentation)
IOH.
WERE
THE
ASSETS
USED
TO
ESTABLISH
A
TRUST?
101.
PROVIDE
TAX
NUMBER
101
PROVIDE
DETAILS
AND ATTACH
DOCUMENTATION
El
Yes
El
No
(If”Yes,”
complete
Items
101
through
IOJ)
10K.
WAS THE
TRUST ESTABLISHED
FOR A
CHILD
OF
THE
VETERAN WHO
WAS
INCAPABLE
OF
SELF-SUPPORT
PRIOR
TO
REACHING
AGE
18?
El
Yes
El
No
VA
FORM
21P-0969,
OCT 2018
Page
1U
Page 78
SECTION
XI
-
WAIVER
OF
RECEIPT
OF
INCOME
(If
additional
space
is
needed attach
a
separate
sheet)
11.
DID
YOU
OR
YOUR
DEPENDENTS WAIVE
OR
EXPECT
TO
WAIVE ANY RECEIPT
OF
INCOME
IN
THE
NEXT
12
MONTHS?
D
YES
NO
(If
NO,
skip this
section.
This attachment
is
complete.
Return
to
the
application. Your certification, signature
and date
on
the
application
form
applies
to
this
attachment)
A.
INCOME
RECIPIENT
B.
WHAT
IS
YOUR
OR
YOUR DEPENDENTS
CURRENT
(Veteran,
Spouse.
Child,
Parent,
Custodian,
etc.)
ANDIOR
EXPECTED
WAIVED
INCOME?
(Provide
documentation
of
income
and
expected
income
changes)
CURRENT
MONTHLY
GROSS
WAIVED
$
IN
COME
DO
YOU
EXPECT
THIS
WAIVED
INCOME
TO
CHANGE
IN
THE
NEXT
12
MONTHS?
fl
YES
flNo
DATE
WAIVED
INCOME
WILL
CHANGE
AND
EXPECTED
WAIVED
INCOME
AMOUNT
$
CURRENT
MONTHLY
GROSS
WAIVED
$
INCOME
DO
YOU
EXPECT
THIS
WAIVED
INCOME
TO CHANGE
IN
THE NEXT
12
MONTHS?
E
YES
flNo
DATE
WAIVED
INCOME
WILL
CHANGE
AND
EXPECTED
WAIVED
INCOME
AMOUNT
$
CURRENT
MONTHLY
GROSS
WAIVED
$
INCOME
DO
YOU
EXPECT
THIS
WAIVED
INCOME
TO
CHANGE
IN
THE NEXT
12
MONTHS?
fl
YES
END
DATE
WAIVED
INCOME
WILL
CHANGE
AND
EXPECTED
WAIVED
INCOME
AMOUNT
S
CURRENT
MONTHLY
GROSS
WAIVED
S
INCOME
DO
YOU
EXPECT
THIS
WAIVED
INCOME
TO
CHANGE
IN
THE NEXT
12
MONTHS?
~
YES
END
DATE
WAIVED
INCOME
WILL
CHANGE
AND
EXPECTED
WAIVED
INCOME
AMOUNT
S
TI-US
ATTACHMENT
FORM
IS
COMPLETE.
RETURN TO
THE
APPLICATION
FORM.
YOUR
CERTIFICATION, SIGNATURE
AND
DATE
ON
THE
APPLICATION
FORM
APPLIES
TO
THIS
ATTACHMENT.
VA
FORM
21P-0989,
OCT 2018
Page
11
Page 79
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