OMB Approved No. 2900-0101
Respondent Burden: 30 Minutes
Expiration Date: 06/30/2021
FIRST, MIDDLE, LAST NAME OF VETERAN
DIC PARENT'S ELIGIBILITY
VETERAN'S SOCIAL SECURITY NUMBER
VERIFICATION REPORT
4
FIRST, MIDDLE, LAST NAME OF PARENT
VA FILE NUMBER - PAYEE NUMBER - STUB NAME
COMPLETE ADDRESS OF PARENT
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER
1B. YOUR SPOUSE'S SOCIAL SECURITY NUMBER
(Mo., day, year)
(Mo., day, year)
1C. YOUR DATE OF BIRTH
1D. YOUR SPOUSE'S DATE OF BIRTH
(Check only one box)
2. MARITAL STATUS
(You are currently married and live with the veteran's other parent
(1)
MARRIED - LIVING WITH OTHER PARENT OF VETERAN
or you live apart only for medical reasons.)
(You are currently married to a person who
(2)
MARRIED - LIVING WITH SPOUSE WHO IS NOT OTHER PARENT OF VETERAN
is not the veteran's other parent and you live together or live apart only for medical reasons.)
(You are married but estranged from your spouse.)
(3)
SEPARATED FROM SPOUSE
If you are separated within the last 12 months,
show the date of separation
.
(You have never married or are now divorced or widowed.)
(4)
NOT NOW MARRIED
If your most recent marriage ended during the
last 12 months, enter the date of divorce or the date of your spouse's death.
Date of divorce
Date of spouse's death
3. IS THE OTHER PARENT OF THE VETERAN LIVING?
YES
NO
UNKNOWN
4A. ARE YOU A PATIENT IN A NURSING HOME?
4C. ENTER THE NAME, COMPLETE ADDRESS, AND
(Please
TELEPHONE NUMBER OF THE NURSING HOME
include ZIP Code)
(If "Yes," complete Items 4B and 4C. If "No," go to Item 5)
YES
NO
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
5. WERE YOU OR YOUR SPOUSE EMPLOYED AT ANY TIME DURING THE 12
MONTH PERIOD PRECEDING THE DATE YOU SIGNED THE FORM?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
(If "Yes," write in the VA file number of the other benefit)
YES
NO
21P-0514-1
Page 1
VA FORM
SUPERSEDES VA FORM 21-0514-1, APR 2015,
JUN 2018
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0101
Respondent Burden: 30 Minutes
Expiration Date: 06/30/2021
FIRST, MIDDLE, LAST NAME OF VETERAN
DIC PARENT'S ELIGIBILITY
VETERAN'S SOCIAL SECURITY NUMBER
VERIFICATION REPORT
4
FIRST, MIDDLE, LAST NAME OF PARENT
VA FILE NUMBER - PAYEE NUMBER - STUB NAME
COMPLETE ADDRESS OF PARENT
VA REGIONAL OFFICE RETURN ADDRESS
IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER
1B. YOUR SPOUSE'S SOCIAL SECURITY NUMBER
(Mo., day, year)
(Mo., day, year)
1C. YOUR DATE OF BIRTH
1D. YOUR SPOUSE'S DATE OF BIRTH
(Check only one box)
2. MARITAL STATUS
(You are currently married and live with the veteran's other parent
(1)
MARRIED - LIVING WITH OTHER PARENT OF VETERAN
or you live apart only for medical reasons.)
(You are currently married to a person who
(2)
MARRIED - LIVING WITH SPOUSE WHO IS NOT OTHER PARENT OF VETERAN
is not the veteran's other parent and you live together or live apart only for medical reasons.)
(You are married but estranged from your spouse.)
(3)
SEPARATED FROM SPOUSE
If you are separated within the last 12 months,
show the date of separation
.
(You have never married or are now divorced or widowed.)
(4)
NOT NOW MARRIED
If your most recent marriage ended during the
last 12 months, enter the date of divorce or the date of your spouse's death.
Date of divorce
Date of spouse's death
3. IS THE OTHER PARENT OF THE VETERAN LIVING?
YES
NO
UNKNOWN
4A. ARE YOU A PATIENT IN A NURSING HOME?
4C. ENTER THE NAME, COMPLETE ADDRESS, AND
(Please
TELEPHONE NUMBER OF THE NURSING HOME
include ZIP Code)
(If "Yes," complete Items 4B and 4C. If "No," go to Item 5)
YES
NO
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
5. WERE YOU OR YOUR SPOUSE EMPLOYED AT ANY TIME DURING THE 12
MONTH PERIOD PRECEDING THE DATE YOU SIGNED THE FORM?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
(If "Yes," write in the VA file number of the other benefit)
YES
NO
21P-0514-1
Page 1
VA FORM
SUPERSEDES VA FORM 21-0514-1, APR 2015,
JUN 2018
WHICH WILL NOT BE USED.
(Read Paragraphs 2 and 3 of the EVR instructions)
7A. MONTHLY INCOME
(If no income was received from a particular source, write "0" or "none." VA WILL INTERPRET A BLANK SPACE AS "NONE or "0." )
GROSS MONTHLY AMOUNTS
SOURCE
YOU
YOUR SPOUSE
SOCIAL SECURITY
$
$
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
MILITARY RETIREMENT
(Show Source)
OTHER
(Show Source)
OTHER
(Read Paragraphs 2 and 4 of the EVR Instructions)
7B. ANNUAL INCOME
If no income was received from a particular source, write "0" or "none." VA WILL INTERPRET A BLANK SPACE AS "NONE" or "0."
YOU
YOUR SPOUSE
SOURCE
FROM:
FROM:
FROM:
FROM:
THRU:
THRU:
THRU:
THRU:
GROSS WAGES FROM
$
$
ALL EMPLOYMENT
TOTAL INTEREST AND
DIVIDENDS
ALL OTHER
(Show Source)
ALL OTHER
(Show Source)
(Increase/Decrease)
(Answer "NO" if there were no income changes or if the only
7C. 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)
YES
(If "Yes," complete Items 7D through 7F. If "No," go to Item 8)
NO
7F. HOW DID INCOME CHANGE?
7D. WHAT INCOME CHANGED?
7E. WHEN DID THE INCOME CHANGE?
(Explain what happened; for example, quit
(Show what income changed; for
(Show the dates you received any new
work, got raise, received inheritance)
example, wages, city pension, etc.)
income or the date income changed)
(Read Paragraph 6 of the EVR Instructions)
8. MEDICAL EXPENSES
Normally, medical expenses are reported at the end of the year. If you are using this form as your annual Eligibility Verification Report
and Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21P-8416, Medical Expense
Report, to report your medical expenses. If you are using this form as a supplement to a pending claim, you do not need to report medical
expenses. If entitlement is established, you will have an opportunity to report your medical expenses at the end of the year.
(Read paragraph 9 of the EVR Instructions before signing)
9B. DATE SIGNED
9A. SIGNATURE OF PARENT
(Include Area Code)
9C. TELEPHONE NUMBERS
DAYTIME
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.
PAGE 2
VA FORM 21P-0514-1, JUN 2018
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