APPLICATION FOR EXCLUSION OF CHILDREN'S INCOME
OMB Control No. 2900-0510
Respondent Burden: 45 minutes
Expiration Date: 03/31/2021
VA FORM
MAR 2018
IMPORTANT: VA can exclude all or some of your children's income in computing your rate of pension if counting the children's income would cause hardship or if
this income is unavailable to you. Please fully complete this form if you wish to claim the exclusion.
21P-0571
SUPERSEDES VA FORM 21-0571, NOV 2014,
WHICH WILL NOT BE USED.
Page 1
ITEMS
6. CHILD'S DATE OF BIRTH
7. CHILD'S SOCIAL SECURITY NUMBER
CHILD'S NAME CHILD'S NAME CHILD'S NAME
8. IS ALL OF THIS CHILD'S INCOME
REASONABLY AVAILABLE TO YOU?
(If "No," complete Items 9 thru 13.
If "Yes," skip to Item 14)
9. DESCRIBE THE SPECIFIC INCOME
WHICH IS NOT AVAILABLE TO YOU
(For example, Social Security, wages, etc.)
10. NAME OF PAYEE OF THE INCOME
DESCRIBED IN ITEM 9?
(Whose name
appears on the check?)
11. DOES THE PERSON NAMED IN ITEM
10 RESIDE IN YOUR HOUSEHOLD
ALL YEAR? (If "No," complete Item 12.
If "Yes," skip to Item 13)
12. HOW MANY MONTHS DID THE
PERSON NAMED IN ITEM 10 RESIDE
IN YOUR HOUSEHOLD DURING THE
12 MONTHS PRECEDING THE DATE
YOU ARE SIGNING THIS FORM?
13. USE THIS SPACE TO FURNISH ANY
OTHER INFORMATION AS TO WHY
YOU FEEL THIS CHILD'S INCOME IS
NOT REASONABLY AVAILABLE TO
YOU
(If you need more space, use Item 17)
YES NO YES NO YES NO YES NO
YES NO YES NO YES NO YES NO
CHILD'S NAME
1. FIRST, MIDDLE, LAST NAME OF VETERAN
3. NAME OF CLAIMANT
(If other than veteran)
2. VA FILE NUMBER
4. VETERAN'S SOCIAL SECURITY NUMBER
5. ADDRESS OF CLAIMANT (Number and street or rural route, City or P. O., State, and ZIP Code)
PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy
Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or
research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs
and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation,
Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond to obtain or retain
benefits. Giving us your and your dependents' SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for
whom benefits are claimed under Title 38 USC 5101 (c) (1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of
the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to
determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification
through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine whether we can exclude all or part of your children's income on the basis of hardship (38 U.S.C.
1521 and 38 U.S.C. 1541). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 45 minutes to review the
instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed.
You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.reginfo.gov/public/do/PRAMain
. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
