Fillable VBA-21P-0969-ARE VA Form 21P-0969

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VBA-21P-0969-ARE VA Form 21P-0969

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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:
• 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 (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:
• 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 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)
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.
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
PARENT
SURVIVING CHILD
SURVIVING SPOUSE
VETERAN
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
Page 1
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)
Page 2
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?
B. WHO IS THE INCOME PAYER?
(Name of business, financial
institution, etc.)
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
CURRENT MONTHLY
GROSS INCOME
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
YES
NO
YES NO
YES NO
C. WHAT IS YOUR CURRENT
AND/OR EXPECTED INCOME?
(Provide documentation of current income and
expected income changes)
YES
NO
SECTION I: RETIREMENT INCOME AND DISTRIBUTIONS (If additional space is needed attach a separate sheet)
D. WHAT IS THE TOTAL
CASH VALUE OF THE
ASSET
ASSOCIATED WITH
THIS INCOME?
(Provide documentation of
assets)
INCOME AND ASSET STATEMENT IN SUPPORT OF CLAIM FOR PENSION OR
PARENTS' DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
(Attachment to VA Forms 21P- 527, 21P-527EZ, 21P-534, and 21P-534EZ)
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 Retirement
• IRA
• SEP
• Qualified Plans
• Pensions
• Annuities
• Black Lung
(If "No," skip to Section II)
YES
NO
$
A. INCOME RECIPIENT
(Veteran, Spouse, Child,
Parent, Custodian, etc.)
CURRENT MONTHLY
GROSS INCOME
$
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE
NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
CURRENT MONTHLY
GROSS INCOME
$
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
$
$
$
CURRENT MONTHLY
GROSS INCOME
OMB Control No. 2900-0829
Respondent Burden: 25 minutes
Expiration Date: 10/31/2021
21P-0969
VA FORM
OCT 2018
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
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?
VA FORM 21P-0969, OCT 2018
Page 3
(If "No," skip to Section III)
YES
NO
A. INCOME RECIPIENT
(Veteran, Spouse, Child, Parent, Custodian, etc.)
B. WHAT IS YOUR OR YOUR DEPENDENTS CURRENT
AND/OR EXPECTED UNEMPLOYMENT INCOME?
(Provide documentation of current income and
expected income changes)
YES
NO
$
$
CURRENT MONTHLY
GROSS INCOME
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
YES
NO
$
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
YES
NO
$
$
CURRENT MONTHLY
GROSS INCOME
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
YES
NO
$
$
CURRENT MONTHLY
GROSS INCOME
DO YOU EXPECT THIS INCOME
TO CHANGE IN THE NEXT
12 MONTHS?
CURRENT MONTHLY
GROSS INCOME
$
B. WHAT IS YOUR OR YOUR DEPENDENTS CURRENT AND/OR
EXPECTED ANNUAL INCOME (interest earned)?
(Attach a copy of the savings bond)
A. WHO OWNS THE SAVINGS BOND?
(Veteran, Spouse, Child, Parent,
Custodian, etc.)
SECTION III - SAVINGS BONDS (If additional space is needed attach a separate sheet)
C. WHAT IS THE CURRENT
FACE VALUE
OF THE
SAVINGS BOND?
Page 4
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?
(If "No," skip to Section IV)
YES
NO
$
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
$
$
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
$
YES
NO
YES
NO
WHAT IS THE GROSS ANNUAL
INCOME?
WHAT IS THE GROSS ANNUAL
INCOME?
$
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
$
YES
NO
WHAT IS THE GROSS ANNUAL
INCOME?
$
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
$
YES
NO
WHAT IS THE GROSS ANNUAL
INCOME?
VA FORM 21P-0969, OCT 2018
A. INCOME RECIPIENT
(Veteran, Spouse, Child,
Parent,
Custodian, etc.)
D. WHAT IS THE VALUE OF YOUR
PORTION OF THE PROPERTY, FARM,
OR BUSINESS?
(Note: Subtract the amount of Mortgages or
other encumbrances specific to the property.
Provide available documentation)
VA FORM 21P-0969, OCT 2018
Page 5
CURRENT MONTHLY
GROSS INCOME
$
YES
NO
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed
VA Form 21P-4185 with this application
Business - Submit a completed
VA Form 21P-4185 with this application
CURRENT MONTHLY
GROSS INCOME
YES
NO
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed
VA Form 21P-4185 with this application
Business - Submit a completed
VA Form 21P-4185 with this application
SECTION IV - RENTAL PROPERTY, FARM OR BUSINESS INCOME (If additional space is needed attach a separate sheet)
4. ARE YOU OR YOUR DEPENDENTS RECEIVING OR EXPECTING TO RECEIVE, INCOME FROM RENTAL PROPERTY, FARM OR BUSINESS WITHIN THE NEXT
12 MONTHS?
(If "No," skip to Section V)
YES
NO
B. WHAT IS YOUR OR YOUR
DEPENEDENTS CURRENT OR
EXPECTED INCOME
FROM THIS SOURCE?
(Provide documentation of current income
and
expected income changes)
C. WHAT KIND OF INCOME
IS THIS?
(Check applicable box)
$
YES
NO
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed
VA Form 21P-4185 with this application
Business - Submit a completed
VA Form 21P-4185 with this application
CURRENT MONTHLY
GROSS INCOME
Farm - Submit a completed
VA Form 21P-4165 with this application
Rental Property - Submit a completed
VA Form 21P-4185 with this application
Business - Submit a completed
VA Form 21P-4185 with this application
CURRENT MONTHLY
GROSS INCOME
$
YES
NO
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
$
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
DO YOU EXPECT THIS INCOME TO
CHANGE IN THE NEXT 12 MONTHS?
D. WHAT IS THE TOTAL CASH
VALUE OF THE ASSET
ASSOCIATED WITH THIS
INCOME?
(Provide documentation of
assets)
VA FORM 21P-0969, OCT 2018
Page 6
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?
(If "No," skip to Section VI)
YES
NO
A. INCOME RECIPIENT
(Veteran, Spouse, Child,
Parent, Custodian, etc.)
B. WHO IS THE INCOME PAYER?
(Name of business,
financial institution, etc.)
C. WHAT IS YOUR OR YOUR DEPENDENTS
CURRENT AND/OR EXPECTED INCOME?
(Provide documentation of current income and
expected income changes)
IMPORTANT: Do not report income you have already reported in Section III (Savings Bonds) or Section IV (Rental Property, Farm or Business 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
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
NO
DATE INCOME
WILL CHANGE AND EXPECTED
INCOME AMOUNT
$
CURRENT MONTHLY
GROSS INCOME
B. WHAT ARE YOUR OR YOUR DEPENDENTS CURRENT WAGES
AND/OR EXPECTED WAGES?
(Provide documentation of current wages and expected wage changes)
A. WAGE RECIPIENT
(Veteran, Spouse, Child, Parent,
Custodian, etc.)
VA FORM 21P-0969, OCT 2018
Page 7
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?
(If "No," skip to Section VII)
YES
NO
$
DO YOU EXPECT THIS WAGE INCOME TO CHANGE IN THE
NEXT 12 MONTHS?
YES
NO
DATE WAGE INCOME
WILL CHANGE AND EXPECTED
WAGE AMOUNT
$
CURRENT MONTHLY
GROSS WAGE
$
DO YOU EXPECT THIS WAGE INCOME TO CHANGE IN THE
NEXT 12 MONTHS?
YES
NO
DATE WAGE INCOME
WILL CHANGE AND EXPECTED
WAGE AMOUNT
$
CURRENT MONTHLY
GROSS WAGE
$
DO YOU EXPECT THIS WAGE INCOME TO CHANGE IN THE
NEXT 12 MONTHS?
YES
NO
DATE WAGE INCOME
WILL CHANGE AND EXPECTED
WAGE AMOUNT
$
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
$
CURRENT MONTHLY
GROSS WAGE
SECTION VII - DISCONTINUED INCOME IN THE PRIOR TAX YEAR (If additional space is needed attach a separate sheet)
VA FORM 21P-0969, OCT 2018
Page 8
7. DID YOU OR YOUR DEPENDENTS RECEIVE INCOME LAST YEAR THAT IS NO LONGER BEING RECEIVED OR WAS A ONE-TIME PAYMENT?
(If "No," skip to Section VIII)
YES
NO
A. INCOME RECIPIENT
(Veteran, Spouse, Child, Parent, Custodian, etc.)
B. WHO WAS THE INCOME PAYER?
(Name of business, financial institution, etc.)
$
C. WHAT WAS THE GROSS
ANNUAL AMOUNT
REPORTED TO THE IRS?
$
$
$
D. WHEN DID THE
INCOME STOP?
(MM,DD,YYYY)
8. DO YOU OR YOUR DEPENDENTS HAVE ASSETS NOT ALREADY REPORTED, SUCH AS NON-INTEREST-BEARING ACCOUNTS, CASH, STOCKS,
BONDS, OR REAL ESTATE?
NOTE: Parent's DIC 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.
D. DETAILS OF THE ASSET TRANSFER
(Provide documentation of the transfer. A transfer for less than fair
market value means you disposed of an asset for less than the asset
was worth)
C. AMOUNT OWED ON THE ASSET OR
AMOUNT MORTGAGED OR OTHERWISE
ENCUMBERED?
(Provide documentation of mortgages or other
encumbrances
)
A. ASSET OWNER
(Veteran, Spouse, Child, Parent,
Custodial, etc.)
B. WHAT IS THE CURRENT CASH VALUE
OF THE ASSET?
(Provide a bank or other official statement showing
the current value. Do not report assets you have already
reported in Sections I through VII)
SECTION VIII - ASSETS PREVIOUSLY NOT REPORTED (If additional space is needed attach a separate sheet)
VA FORM 21P-0969, OCT 2018
Page 9
(If "No," skip to Section IX)
YES
NO
$
$
$
$
$
$
$
$
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?
YES
NO
(If "No," skip to Section X)
A. WHO OWNED THE ASSET?
(Veteran, Spouse, Child, Parent,
Custodian, etc.)
B. HOW WAS THE
ASSET TRANSFERRED?
C. WHO DID YOU
TRANSFER
THE ASSET TO?
SOLD
CONVEYED
GAVE AWAY
TRADED
OTHER (Explain below)
SOLD
CONVEYED
GAVE AWAY
TRADED
OTHER (Explain below)
Name:
_____________________
Relationship:
_____________________
Name:
_____________________
Relationship:
_____________________
Was the asset transferred for less than fair market value?
Yes No
Was an asset reported to the IRS sold?
Yes No
What was the original purchase price?_____________________
What was the sale price?_____________________
What was the gain (capital gain, etc.)?_____________________
Was the asset transferred for less than fair market value?
Yes No
Was an asset reported to the IRS sold?
Yes No
What was the original purchase price?_____________________
What was the sale price?_____________________
What was the gain (capital gain, etc.)?_____________________
What date was the asset sold?
(MM,DD,YYYY)_______________
What date was the asset sold?
(MM,DD,YYYY)_______________
SECTION X: ANNUITIES AND TRUSTS (Attach a separate sheet if more than one annuity or trust is involved)
Yes
10A. 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?
10K. WAS THE TRUST ESTABLISHED FOR A CHILD OF THE VETERAN WHO WAS INCAPABLE OF SELF-SUPPORT PRIOR TO REACHING AGE 18?
C. WHO DID YOU
TRANSFER
THE ASSET TO?
Page 10
SECTION IX: ASSET TRANSFERS (Continued)
A. WHO OWNED THE ASSET?
(Veteran, Spouse, Child,
Parent, Custodian, etc.)
SOLD
CONVEYED
GAVE AWAY
TRADED
OTHER (Explain below)
Name:
_____________________
Relationship:
_____________________
Was the asset transferred for less than fair market value?
Yes No
Was an asset that was reported to the IRS sold?
Yes No
What was the original purchase price?_____________________
What was the sale price?_____________________
What was the gain (capital gain, etc.)?_____________________
D. DETAILS OF THE ASSET TRANSFER
(Provide documentation of the transfer. A transfer for less than fair
market value means you disposed of an asset for less than the asset
was worth)
SOLD
CONVEYED
GAVE AWAY
TRADED
OTHER (Explain below)
Name:
_____________________
Relationship:
_____________________
Was the asset transferred for less than fair market value?
Yes No
Was an asset that was reported to the IRS sold?
Yes No
What was the original purchase price?_____________________
What was the sale price?_____________________
What was the gain (capital gain, etc.)?_____________________
Yes
No
(If "No," skip to Section XI)
10B. WHAT WAS THE MARKET VALUE OF THE ASSET AT THE TIME OF TRANSFER OR ANNUITY PURCHASE?
10D. DID YOU PURCHASE AN ANNUITY WITH THE ASSETS?
Yes
No
(If "Yes," complete Items 10E through 10G)
10H. WERE THE ASSETS USED TO ESTABLISH A TRUST?
10C. WHAT WAS THE DATE THE ASSET WAS TRANSFERRED?
(MM,DD,YYYY)
10F. PROVIDE NAME OF PERSON THE ASSET WAS
PURCHASED FROM (First-Middle-Last)
10G. PROVIDE TYPE OF ANNUITY PURCHASED (Give details and attach documentation)
$
Yes
No
(If "Yes," complete Items 10I through 10J)
10I. PROVIDE TAX NUMBER
10J. PROVIDE DETAILS AND ATTACH DOCUMENTATION
No
B. HOW WAS THE
ASSET TRANSFERRED?
10E. PROVIDE DATE OF PURCHASE
What date was the asset sold?
(MM,DD,YYYY)_______________
What date was the asset sold?
(MM,DD,YYYY)_______________
VA FORM 21P-0969, OCT 2018
B. WHAT IS YOUR OR YOUR DEPENDENTS CURRENT
AND/OR EXPECTED WAIVED INCOME?
(Provide documentation of income and
expected income changes)
A. INCOME RECIPIENT
(Veteran, Spouse, Child, Parent, Custodian, etc.)
VA FORM 21P-0969, OCT 2018
Page 11
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?
YES
NO
THIS ATTACHMENT FORM IS COMPLETE. RETURN TO THE APPLICATION FORM. YOUR CERTIFICATION, SIGNATURE AND DATE
ON THE APPLICATION FORM APPLIES TO THIS ATTACHMENT.
$
YES
NO
$
CURRENT MONTHLY
GROSS WAIVED
INCOME
DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
$
YES
NO
$
CURRENT MONTHLY
GROSS WAIVED
INCOME
DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
$
YES
NO
$
CURRENT MONTHLY
GROSS WAIVED
INCOME
DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
$
YES
NO
$
CURRENT MONTHLY
GROSS WAIVED
INCOME
DO YOU EXPECT THIS WAIVED INCOME TO CHANGE IN THE NEXT 12 MONTHS?
DATE WAIVED INCOME WILL CHANGE AND EXPECTED
WAIVED INCOME AMOUNT
(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)
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VBA-21P-0969-ARE VA Form 21P-0969

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Completed 8 May 2020

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