VA Form 21P-4165 "Pension Claim Questionnaire for Farm Income"

VA Form 21P-4165 is a U.S. Department of Veterans Affairs form also known as the "Pension Claim Questionnaire For Farm Income". The latest edition of the form was released in November 1, 2016 and is available for digital filing.

Download a PDF version of the VA Form 21P-4165 down below or find it on U.S. Department of Veterans Affairs Forms website.

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Download VA Form 21P-4165 "Pension Claim Questionnaire for Farm Income"

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OMB Approved No. 2900-0095
Respondent Burden: 30 minutes
Expiration Date: 11/30/2019
1. VA FILE NUMBER
PENSION CLAIM QUESTIONNAIRE
FOR FARM INCOME
C/SS-
INSTRUCTIONS: Before further action can be taken on your claim, we must have more information concerning your farming activity. Please
answer all questions on this form accurately and completely. If the answer to a particular question is none, write "NONE" in the space provided.
Please read the Privacy Act and Respondent Burden Information on Page 2 before completing this form.
3. PERIOD ENDING DATE
2. PERIOD STARTING DATE
References in this form to "THIS YEAR" refer to the period
(If blank, "THIS YEAR" refers to the current calendar year.
References to "LAST YEAR" refer to the 12 month period
preceding "THIS YEAR".)
6. SOCIAL SECURITY NUMBER OF CLAIMANT
4. NAME OF VETERAN (First, Middle, Last)
5. NAME OF CLAIMANT (First, Middle, Last)
7. REPORT OF THE TOTAL OF ALL GROSS RECEIPTS
c.)
(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, et
B. AMOUNT EXPECTED THIS YEAR
C. AMOUNT ANTICIPATED NEXT YEAR
A. AMOUNT RECEIVED LAST YEAR
$
$
$
(As shown by deed, trust or other document)
8. NAME(S) OF OWNER(S) OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH
A. NAME OF OWNER OF BUSINESS
B. DEGREE OF OWNERSHIP
9. FARM OPERATING EXPENSES
(Include landlord's share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)
(A) AMOUNT SPENT LAST YEAR
(B) AMOUNT SPENT LAST YEAR
(C) AMOUNT SPENT THIS YEAR
HIRED LABOR
FEEDS PURCHASED
SUPPLIES PURCHASED
MACHINE HIRE
REPAIRS AND MAINTENANCE OF FARM BUILDINGS AND MACHINERY
(Except dwellings)
CASH RENT
PROPERTY TAXES
INSURANCE ON
PROPERTY
INTEREST ON MORTGAGE AND OTHER LOANS
(Not payment on principal)
TOTAL EXPENSES
$
$
21P-4165
VA FORM
SUPERSEDES VA FORM 21-4165, JUN 2013,
Page 1
NOV 2016
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0095
Respondent Burden: 30 minutes
Expiration Date: 11/30/2019
1. VA FILE NUMBER
PENSION CLAIM QUESTIONNAIRE
FOR FARM INCOME
C/SS-
INSTRUCTIONS: Before further action can be taken on your claim, we must have more information concerning your farming activity. Please
answer all questions on this form accurately and completely. If the answer to a particular question is none, write "NONE" in the space provided.
Please read the Privacy Act and Respondent Burden Information on Page 2 before completing this form.
3. PERIOD ENDING DATE
2. PERIOD STARTING DATE
References in this form to "THIS YEAR" refer to the period
(If blank, "THIS YEAR" refers to the current calendar year.
References to "LAST YEAR" refer to the 12 month period
preceding "THIS YEAR".)
6. SOCIAL SECURITY NUMBER OF CLAIMANT
4. NAME OF VETERAN (First, Middle, Last)
5. NAME OF CLAIMANT (First, Middle, Last)
7. REPORT OF THE TOTAL OF ALL GROSS RECEIPTS
c.)
(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, et
B. AMOUNT EXPECTED THIS YEAR
C. AMOUNT ANTICIPATED NEXT YEAR
A. AMOUNT RECEIVED LAST YEAR
$
$
$
(As shown by deed, trust or other document)
8. NAME(S) OF OWNER(S) OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH
A. NAME OF OWNER OF BUSINESS
B. DEGREE OF OWNERSHIP
9. FARM OPERATING EXPENSES
(Include landlord's share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)
(A) AMOUNT SPENT LAST YEAR
(B) AMOUNT SPENT LAST YEAR
(C) AMOUNT SPENT THIS YEAR
HIRED LABOR
FEEDS PURCHASED
SUPPLIES PURCHASED
MACHINE HIRE
REPAIRS AND MAINTENANCE OF FARM BUILDINGS AND MACHINERY
(Except dwellings)
CASH RENT
PROPERTY TAXES
INSURANCE ON
PROPERTY
INTEREST ON MORTGAGE AND OTHER LOANS
(Not payment on principal)
TOTAL EXPENSES
$
$
21P-4165
VA FORM
SUPERSEDES VA FORM 21-4165, JUN 2013,
Page 1
NOV 2016
WHICH WILL NOT BE USED.
10A. PROVIDE THE TOTAL ACREAGE OWNED BY YOU
10B. IS YOUR PRIMARY RESIDENCE LOCATED ON THE ACREAGE YOU OWN?
YES
NO
(If "Yes", complete Items 7C and 7D)
10D. WHAT IS THE SPECIFIC VALUE OF THE ACREAGE RELATED TO YOUR
10C. HOW MANY OF THE ACRES YOU OWN ARE CONSIDERED
PART OF YOUR PRIMARY RESIDENCE?
PRIMARY RESIDENCE?
$
11. ACREAGE IN CROPS AND PASTURE
12. LIVESTOCK INFORMATION
NUMBER OF ACRES
(B) TOTAL NUMBER
(A) KIND
(A) KIND
(Cattle, pigs, sheep, ducks, etc.)
(Grain, hay, cotton, tobacco, etc.)
ON FARM NOW
(B) LAST YEAR
(C) THIS YEAR
PASTURE
13. DO YOU RENT YOUR FARM TO OR FROM SOMEONE ELSE?
(If "Yes", furnish a copy of your farm rental agreement or lease or a statement setting forth in detail particulars of the agreement)
YES
NO
14. REMARKS (If any)
CERTIFICATION AND SIGNATURE OF CLAIMANT
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
15B. DATE SIGNED
16. ADDRESS
(Sign in ink)
15A. SIGNATURE OF CLAIMANT
(Including Area Code)
(Including Area Code)
17A. DAYTIME PHONE NO.
17B. EVENING PHONE NO.
WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK
Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and
addresses of such witnesses must be shown below.
(Sign in ink)
18B. PRINTED NAME AND ADDRESS OF WITNESS
18A. SIGNATURE OF WITNESS
(Sign in ink)
19A. SIGNATURE OF WITNESS
19B. PRINTED NAME AND ADDRESS OF WITNESS
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 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, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is required to obtain or retain benefits. 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 the purposed stated above. 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.
RESPONDENT BURDEN: We need this information to determine eligibility for disability pension under 38 U.S.C. 1521, death pension under 38 U.S.C. 1521, death pension under 38 U.S.C.
1315, death compensation under 38 U.S.C. 1121, or Parents' dependency and indemnity compensation under 38 U.S.C. 1315. We estimate that you will need an average of 30 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 1-877-294-6380 to get information on where to send comments or suggestions about this form.
VA FORM 21P-4165, NOV 2016
Page 2
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