VA Form 21-0513-1 Old Law and Section 306 Verification Report (Children Only)

VA Form 21-0513-1 is a United States Department of Veterans Affairs form also known as the "Old Law And Section 306 Verification Report (children Only)".

The form was last revised on June 1, 2004 - download an up-to-date fillable PDF VA Form 21-0513-1 down below or find it on the Veterans Affairs Forms website.

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OMB Control No. 2900-0101
Respondent Burden: 30 minutes
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN
OLD LAW AND SECTION 306
VETERAN'S SOCIAL SECURITY NUMBER
VERIFICATION REPORT
3
(CHILDREN ONLY)
NAME OF CHILD'S CUSTODIAN
VA FILE NUMBER
COMPLETE MAILING ADDRESS OF CHILD OR CUSTODIAN
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21-0510) before completing this form. This form is used by children and
custodians of children receiving Old Law or Section 306 Pension. If you have been receiving a fixed rate of pension since 1960, you receive Old Law
Pension. If you have been receiving a fixed rate of pension since 1978, you receive Section 306 pension. If you receive Old Law Pension, do not
complete Item 2G, Net Worth, and Item 3, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1. CHILD(REN)'S MARITAL AND SCHOOL STATUS
List the children's names, dates of birth, and Social Security numbers, and indicate marital and school status for all children being paid on
this award. If the child does not have a Social Security number, write "No SSN" in the space provided for the child's Social Security
number. If other children are on separate VA awards, they will receive their own EVRs. If additional space is needed, attach a separate
sheet of paper.
NOTE: Complete Item 1E only if the child is 18 years of age or older. Complete Item 1F only if the child is between the ages of 18 and
23 and has not been rated disabled by VA. The child is considered to have attended school continuously if the child attended every
regular school term except summer school or holiday periods. If Block (2), STOPPED SCHOOL, is checked in Item 1E or "NO" is
checked in Item 1F, provide the date the child last attended school in Item 1F.
B. DATE OF
C. SOCIAL
F. ATTENDED SCHOOL
A. FULL NAME OF CHILD
BIRTH
SECURITY
CONTINUOUSLY SINCE
D. MARITAL STATUS
E. SCHOOL STATUS
(First, middle, initial, last)
(Mo., day, yr.)
NUMBER
AGE 18
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
NEVER MARRIED
DISABLED CHILD
NO
(3)
(3)
2. REPORT OF INCOME AND NET WORTH
NOTE: If no income was received from a particular source, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
(Read Paragraphs 2 and 3 of the EVR Instructions)
A. MONTHLY INCOME
CHILD'S NAME:
CHILD'S NAME:
CHILD'S NAME:
SOURCE
$
$
$
SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY
INCOME (SSI)
(Show source)
OTHER INCOME
(Show source)
OTHER INCOME
VA FORM
21-0513-1
SUPERSEDES VA FORM 21-0513-1, JUN 2001,
(Continued on Reverse)
JUN 2004
WHICH WILL NOT BE USED.
OMB Control No. 2900-0101
Respondent Burden: 30 minutes
FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN
OLD LAW AND SECTION 306
VETERAN'S SOCIAL SECURITY NUMBER
VERIFICATION REPORT
3
(CHILDREN ONLY)
NAME OF CHILD'S CUSTODIAN
VA FILE NUMBER
COMPLETE MAILING ADDRESS OF CHILD OR CUSTODIAN
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT: Please read the enclosed EVR Instructions (VA Form 21-0510) before completing this form. This form is used by children and
custodians of children receiving Old Law or Section 306 Pension. If you have been receiving a fixed rate of pension since 1960, you receive Old Law
Pension. If you have been receiving a fixed rate of pension since 1978, you receive Section 306 pension. If you receive Old Law Pension, do not
complete Item 2G, Net Worth, and Item 3, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1. CHILD(REN)'S MARITAL AND SCHOOL STATUS
List the children's names, dates of birth, and Social Security numbers, and indicate marital and school status for all children being paid on
this award. If the child does not have a Social Security number, write "No SSN" in the space provided for the child's Social Security
number. If other children are on separate VA awards, they will receive their own EVRs. If additional space is needed, attach a separate
sheet of paper.
NOTE: Complete Item 1E only if the child is 18 years of age or older. Complete Item 1F only if the child is between the ages of 18 and
23 and has not been rated disabled by VA. The child is considered to have attended school continuously if the child attended every
regular school term except summer school or holiday periods. If Block (2), STOPPED SCHOOL, is checked in Item 1E or "NO" is
checked in Item 1F, provide the date the child last attended school in Item 1F.
B. DATE OF
C. SOCIAL
F. ATTENDED SCHOOL
A. FULL NAME OF CHILD
BIRTH
SECURITY
CONTINUOUSLY SINCE
D. MARITAL STATUS
E. SCHOOL STATUS
(First, middle, initial, last)
(Mo., day, yr.)
NUMBER
AGE 18
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
(3)
(3)
NEVER MARRIED
DISABLED CHILD
NO
DATE LEFT
(1)
(1)
MARRIED
ATTENDS SCHOOL
SCHOOL
(2)
(2)
DIVORCED/WIDOWED
STOPPED SCHOOL
YES
NEVER MARRIED
DISABLED CHILD
NO
(3)
(3)
2. REPORT OF INCOME AND NET WORTH
NOTE: If no income was received from a particular source, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
(Read Paragraphs 2 and 3 of the EVR Instructions)
A. MONTHLY INCOME
CHILD'S NAME:
CHILD'S NAME:
CHILD'S NAME:
SOURCE
$
$
$
SOCIAL SECURITY
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY
INCOME (SSI)
(Show source)
OTHER INCOME
(Show source)
OTHER INCOME
VA FORM
21-0513-1
SUPERSEDES VA FORM 21-0513-1, JUN 2001,
(Continued on Reverse)
JUN 2004
WHICH WILL NOT BE USED.
(Read Paragraphs 2 and 4 of the EVR Instructions)
2B. ANNUAL INCOME
If no income was received, write "0" or "none". DO NOT LEAVE ANY ITEMS BLANK.
CHILD
CHILD
CHILD
SOURCE
FROM:
FROM:
FROM:
FROM:
FROM:
FROM:
THRU:
THRU:
THRU:
THRU:
THRU:
THRU:
GROSS SALARY OR
$
$
$
$
$
$
WAGES
TOTAL INTEREST AND
DIVIDENDS
(Show Source)
ALL OTHER
(Show Source)
ALL OTHER
2C.
(Increase/Decrease)
Answer "NO", if there were no income changes or if the only
DID ANY INCOME CHANGE
DURING THE PAST 12 MONTHS? (
change was a Social Security/VA cost-of-living adjustment. Answer "YES", if there were any other income changes or if you received any NEW
source of income or any ONE-TIME income)
(1)
YES
(2)
NO
(If "YES", complete Items 2D through 2F. If "NO", go to Item 2G.)
2D. WHAT INCOME CHANGED?
2E. WHEN DID INCOME CHANGE?
2F. HOW DID INCOME CHANGE?
(Show what income changed; for
Show the dates you received any new income
(Explain what happened; for example,
(
example, wages, city pension, etc.)
or the date income changed)
quit work, got raise, received inheritance)
2G. NET WORTH (Read Paragraph 5 of the EVR Instructions)
NOTE: Complete only if you receive Section 306 Pension. Skip to Item 4A if you receive Old Law Pension.
SOURCE
CHILD
CHILD
CHILD
CASH, NON-INTEREST-BEARING BANK
$
$
$
ACCOUNTS
INTEREST-BEARING BANK ACCOUNTS
STOCKS, BONDS, MUTUAL FUNDS, ETC.
CERTIFICATES OF DEPOSIT, IRAs, ETC.
(Excluding child's home)
REAL PROPERTY
ALL OTHER PROPERTY
(Read Paragraph 6 of the EVR Instructions)
3. CHILD'S MEDICAL EXPENSES
NOTE: Skip to Item 4A if you receive Old Law Pension.
If Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21-8416, Medical Expense
Report, to report your medical expenses.
(Read Paragraph 9 of the EVR Instructions before signing)
4B. DATE
4A. SIGNATURE OF PAYEE
(Include Area Code)
5. TELEPHONE NUMBERS
A. DAYTIME
B. EVENING
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 21-0513-1, JUN 2004

Download VA Form 21-0513-1 Old Law and Section 306 Verification Report (Children Only)

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