OMB Control No. 2900-0108
Respondent Burden: 30 Minutes
Expiration Date: 04/30/2021
REPORT OF INCOME FROM PROPERTY OR BUSINESS
Privacy Act Notice: 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 is required to obtain
or retain benefits. 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 eligibility for benefits (38 U.S.C. 1315 and 1506). Title 38, United States Code, allows us to ask for this
information. 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
1-800-827-1000 to get information on where to send comments or suggestions about this form.
INSTRUCTIONS: Please provide specific information about the gross income and expenses of your property and/or business, so we can determine eligibility for
benefits. Print all answers clearly. If an answer is "none" or "0," write that or line through the space provided. For additional space, attach a separate sheet, indicating
the item number to which the answers apply. Make sure to write the veteran's name and VA claim number on any attachments to the form.
Rental income: Net rental income is gross rental income less expenses. Depreciation and payments on the principal of a mortgage are not deductible. If the rental
property is partially occupied by the owner, report the gross income received and the proportionate part of the expenses. For example: If you own a two-family house
that is occupied by you and another family, report the gross income you receive from the other family and one-half of the expenses.
Business income: Net business income is gross income less operating expenses. Depreciation, withdrawals of cash or merchandise, and salaries paid you or your
partners are not deductible. Deductible operating expenses include cost of goods sold, rent, normal repairs, taxes (other than Federal income tax), salary or wages of
employees, insurance, interest on business debts, and similar expenses.
For more information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the number is 711. VA forms are available at
www.va.gov/vaforms
1. VETERAN'S NAME (First, Middle Initial, Last)
2. FIRST NAME-MIDDLE NAME-LAST NAME OF CLAIMANT (If other than veteran)
3. MAILING ADDRESS OF CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
6. WHAT PORTION OF RENTAL
4. VA FILE NUMBER
5. TELEPHONE NUMBER (Include Area Code)
PROPERTY, IF ANY, IS OCCUPIED
BY CLAIMANT?
7. ADDRESS OF RENTAL PROPERTY
8. BRIEF DESCRIPTION OF RENTAL PROPERTY (Include number and type
of units)
9. ADDRESS OF BUSINESS
10. TYPE OR NATURE OF BUSINESS
11A. VALUE AT BEGINNING OF CURRENT CALENDAR
11B. VALUE AT END OF CURRENT CALENDAR YEAR
STOCK INVENTORY
YEAR
OF BUSINESS
$
$
(12B)
(12C)
(12A)
EXPENSES FOR THE PERIOD
EXPENSES FOR THE PERIOD
TOTAL EXPENSES RELATING TO RENTAL PROPERTY OR
FROM
THRU
FROM
THRU
LINE
NO.
OPERATION OF BUSINESS
NOTE: Do not list personal expenditures.
(If no dates are shown, report
(If no dates are shown, report
expenses for last calendar year)
expenses for current calendar year)
1
TAXES
$
$
2
UTILITIES (If furnished)
3
INSURANCE
4
INTEREST ON MORTGAGE
5
FUEL (If furnished)
6
NORMAL REPAIRS
21P-4185
Page 1
VA FORM
SUPERSEDES VA FORM 21-4185, MAY 2016, WHICH
APR 2018
WILL NOT BE USED.
OMB Control No. 2900-0108
Respondent Burden: 30 Minutes
Expiration Date: 04/30/2021
REPORT OF INCOME FROM PROPERTY OR BUSINESS
Privacy Act Notice: 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 is required to obtain
or retain benefits. 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 eligibility for benefits (38 U.S.C. 1315 and 1506). Title 38, United States Code, allows us to ask for this
information. 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
1-800-827-1000 to get information on where to send comments or suggestions about this form.
INSTRUCTIONS: Please provide specific information about the gross income and expenses of your property and/or business, so we can determine eligibility for
benefits. Print all answers clearly. If an answer is "none" or "0," write that or line through the space provided. For additional space, attach a separate sheet, indicating
the item number to which the answers apply. Make sure to write the veteran's name and VA claim number on any attachments to the form.
Rental income: Net rental income is gross rental income less expenses. Depreciation and payments on the principal of a mortgage are not deductible. If the rental
property is partially occupied by the owner, report the gross income received and the proportionate part of the expenses. For example: If you own a two-family house
that is occupied by you and another family, report the gross income you receive from the other family and one-half of the expenses.
Business income: Net business income is gross income less operating expenses. Depreciation, withdrawals of cash or merchandise, and salaries paid you or your
partners are not deductible. Deductible operating expenses include cost of goods sold, rent, normal repairs, taxes (other than Federal income tax), salary or wages of
employees, insurance, interest on business debts, and similar expenses.
For more information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us toll-free at 1-800-827-1000. If you use a
Telecommunications Device for the Deaf (TDD), the number is 711. VA forms are available at
www.va.gov/vaforms
1. VETERAN'S NAME (First, Middle Initial, Last)
2. FIRST NAME-MIDDLE NAME-LAST NAME OF CLAIMANT (If other than veteran)
3. MAILING ADDRESS OF CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City
Apt./Unit Number
State/Province
Country
ZIP Code/Postal Code
6. WHAT PORTION OF RENTAL
4. VA FILE NUMBER
5. TELEPHONE NUMBER (Include Area Code)
PROPERTY, IF ANY, IS OCCUPIED
BY CLAIMANT?
7. ADDRESS OF RENTAL PROPERTY
8. BRIEF DESCRIPTION OF RENTAL PROPERTY (Include number and type
of units)
9. ADDRESS OF BUSINESS
10. TYPE OR NATURE OF BUSINESS
11A. VALUE AT BEGINNING OF CURRENT CALENDAR
11B. VALUE AT END OF CURRENT CALENDAR YEAR
STOCK INVENTORY
YEAR
OF BUSINESS
$
$
(12B)
(12C)
(12A)
EXPENSES FOR THE PERIOD
EXPENSES FOR THE PERIOD
TOTAL EXPENSES RELATING TO RENTAL PROPERTY OR
FROM
THRU
FROM
THRU
LINE
NO.
OPERATION OF BUSINESS
NOTE: Do not list personal expenditures.
(If no dates are shown, report
(If no dates are shown, report
expenses for last calendar year)
expenses for current calendar year)
1
TAXES
$
$
2
UTILITIES (If furnished)
3
INSURANCE
4
INTEREST ON MORTGAGE
5
FUEL (If furnished)
6
NORMAL REPAIRS
21P-4185
Page 1
VA FORM
SUPERSEDES VA FORM 21-4185, MAY 2016, WHICH
APR 2018
WILL NOT BE USED.
VETERAN'S SOCIAL SECURITY NO.
7
COST OF GOODS SOLD
8
RENT
9
EMPLOYEES' SALARIES
10
INTEREST ON BUSINESS DEBT
11
OTHER (Explain briefly in Item 13, "Remarks" )
12
TOTAL EXPENSES
$
$
IMPORTANT: Report total gross income in Line 1, total expenses in Line 2, and total net income in Line 3. If the property or
business is owned jointly, report your share of the net income in Line 4 and your fractional share of property ownership in Line 5. List
the name(s), address(es), and fractional share(s) of ownership for all remaining owner(s) in Line 6. If your spouse and/or dependent
child(ren) are joint owners, report their net property or business income in Item 14, " Remarks."
(13B)
(13C)
EXPENSES FOR THE PERIOD
EXPENSES FOR THE PERIOD
(13A)
FROM
THRU
FROM
THRU
LINE
GROSS INCOME, TOTAL EXPENSES, AND NET INCOME
NO.
FROM PROPERTY OR BUSINESS
(If no dates are shown, report expenses
(If no dates are shown, report
for last calendar year)
expenses for current calendar year)
1
GROSS INCOME FROM RENTAL PROPERTY AND BUSINESS
$
$
2
TOTAL EXPENSES (Enter total from line 12, above)
$
$
NET INCOME FROM RENTAL PROPERTY OR RECEIPTS
3
$
$
FROM BUSINESS (Subtract line 2 from line 1)
NOTE: Complete Items 4, 5, and 6 only if property or business is owned jointly.
CLAIMANT'S SHARE OF NET INCOME FROM RENTAL
4
$
$
PROPERTY OR RECEIPTS FROM BUSINESS
SHARE OF PROPERTY OR BUSINESS OWNED BY
5
CLAIMANT (Fractional)
LIST THE NAME(S), ADDRESS(ES), AND FRACTIONAL SHARES(S) OF OWNERSHIP FOR ALL REMAINING OWNERS
6
14. REMARKS
I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge.
(Sign in ink)
15B. DATE
15A. SIGNATURE OF CLAIMANT
(Including Area Code)
(Including Area Code)
16A. DAYTIME TELEPHONE NUMBER
16B. EVENING TELEPHONE NUMBER
WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK: Signature made by mark must be witnessed by two
persons who know the claimant personally, and the signatures and addresses of such witnesses must be shown below.
(Sign in ink)
17B. PRINTED NAME AND ADDRESS OF WITNESS
17A. SIGNATURE OF WITNESS
(Sign in ink)
18B. PRINTED NAME AND ADDRESS OF WITNESS
18A. SIGNATURE OF WITNESS
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material
fact knowing it to be false.
VA FORM 21P-4185, APR 2018
Page 2
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