VETERAN/CLAIMANT PERSONAL INFORMATION
IMPORTANT INFORMATION 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 in excess of
being suitable and consistent with a reasonable mode of life.
If you are a Veteran, you must report income and assets for:
• your spouse (unless you live apart and you are estranged and you do not contribute to your spouse's support)
• your child or children (unless 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:
• 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's custodian (unless the child's custodian is an institution)
• custodian's spouse
If you are a Parent, you must report income** for:
• your spouse (even if your spouse is the veteran's other parent. If your spouse is the veteran's other parent, you
must both 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
legally removed. For pension purposes, a child who has attained age 18 remains in the custody of the person who had custody before the child
turned age 18 unless custody is legally removed.
** Parent's DIC claimants do not need to report or provide documentation of their assets.
(1) Section VI on VA Form 21P-527 or Section VIII on VA Form 21P-527EZ.
(2) Section VII on VA Form 21P-534 or Section VIII on VA Form 21P-534EZ.
7. TYPE OF CLAIMANT (Check only one box)
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.
4. CLAIMANT'S NAME (Last, First, Middle)
1. VETERAN'S NAME (Last, First, Middle)
2. VETERAN'S SOCIAL SECURITY NUMBER
3. VETERAN'S FILE NUMBER (If known)
5. CLAIMANT'S SOCIAL SECURITY NUMBER
6. CLAIMANT'S TELEPHONE NUMBER
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, 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, Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is
required to obtain or retain benefits. The requested information is considered relevant and necessary to determine maximum benefits provided under the law. Giving us your SSN account information is
voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for 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 1, 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.
RESPONDENT BURDEN: We need this information to determine your eligibility for pension. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an
average of 25 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed.
You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at: www.reginfo.gov/public/do/
PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM 21P-0969, OCT 2018
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:
INCOME AND ASSET STATEMENT IN SUPPORT OF CLAIM FOR PENSION OR
PARENT'S DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
(Attachment to VA Forms 21P-527, 21P-527EZ, 21P-534, and 21P-534EZ)