VA Form 21p-527EZ "Application for Veterans Pension"

VA Form 21p-527EZ, Application for Pension

VA Form 21p-527EZ, Application for Pension is used by veterans to claim a pension from the U.S. Department of Veterans Affairs (VA). Basing on the information provided in this application and supporting documents, the VA determines whether you are eligible for the corresponding pension benefits.

The latest version of the form was released by the VA in October 2018 and superseded now obsolete VA Form 21-527EZ. An up-to-date fillable VA Form 21p-527EZ is available for download below or can be found on the VA official website.

This document allows you to submit your application via the Fully Developed Claim (FDC) Program. FDC is the fastest way to get the claim processed. There is no risk in participating in the program. If you turn out to be ineligible for FDC, your claim will still be processed, but through the Standard Claim Process.

VA 21p-527EZ consists of 12 pages. The first four pages include FDC criteria, explanation of FDC benefits, comparison of FDC and Standard Claim Process, and the list of evidence necessary to provide to substantiate the pension claim. Pages 5 through 9 contain the application you need to complete. On page 10, you can find the addresses of Pension Centers to mail the application to. The last two pages are additional worksheets in case you are claiming reimbursement for an in-home attendant, assisted living facility, adult day care, or similar expenses.

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VA Form 21p-527EZ Instructions

Form 21p-527EZ filling out instructions are as follows:

  1. Enter your basic identification, contact, and claim information in Section I. If you claim a pension based on disability rather than age 65 or older, it is necessary to list here all disabilities that prevent you from working and the list of the center where you were treated.
  2. Your detailed military service data must be indicated in Section II. The fields of this part are self-explanatory.
  3. In Section III, provide details about disabilities that prevent you from working. Besides, this part should include full information about all your employment for one year before you became disabled.
  4. Sections IV and V are for description of your marital status and current marital status correspondingly. If you have never been married, check the corresponding box in Item 19A and skip this part.
  5. If you have any dependent children (including biological, adopted, or stepchildren) whether living with you or not, indicated this in Section VI.
  6. Provide your and your dependents' (if any) income and assets in Section VII. If the space provided is not enough, you may attach a separate sheet.
  7. The unreimbursed medical expenses for the last year must be listed in Section VIII. If you need more space, you can attach a VA Form 21P-8416, Medical Expense Report. It is not allowed to include here any expenses for which you or your dependents were or will be reimbursed.
  8. Section IX is for direct deposit information. If you have no bank account, you must receive pension payments through Direct Express Debit MasterCard.

A completed VA Form 21p-527EZ must be hand signed and mailed or faxed to a local Pension Center. If you sign with "X", the form should include addresses and signatures of two witnesses as well.

Download VA Form 21p-527EZ "Application for Veterans Pension"

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NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
VETERANS PENSION BENEFITS
(This notice is applicable to veterans claims for: Veterans Pension (a needs based benefit) • Special Monthly Pension • Benefits
Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for veterans pension.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and
there is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans pension, simply submit your
claim in accordance with the "FDC Criteria" shown below. If you are making a claim for veterans disability compensation or related
compensation benefits, use VA Form 21-526EZ, Application for Disability
Compensation and Related Compensation Benefits. If you are making a claim for survivor benefits, use
VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or Accrued Benefits.
VA forms are available at www.va.gov/vaforms.
FDC Criteria (Claim(s) for Veterans Pension Benefits
1. Submit your claim on a signed and completed VA Form 21P-527EZ, Application for Veterans Pension (attached).
.
2. Submit simultaneously with your claim:
.
All necessary income and asset information; AND
All, if any, relevant, private medical treatment records and an identification of any relevant
treatment records available at a Federal facility, such as a VA medical center.
Note: Read the Important note below and attach current medical evidence showing that you are permanently and totally
disabled, if necessary.
IMPORTANT: If you are a veteran who is claiming pension and you are age 65 or older, or determined to be disabled
by the Social Security Administration, you DO NOT have to submit medical evidence with your application unless you
are claiming special monthly pension. Special monthly pension is an increased amount paid to individuals who, due to
mental or physical disability, require the aid of another person to perform activities of daily living, are a patient in a
nursing home, have severe visual problems, or are substantially confined to his or her home.
Special Circumstances
Under the special circumstances shown below, you must also submit simultaneously with your claim:
.
If claiming veterans pension with special monthly pension, a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a nursing home)
.
a completed VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid
and Attendance;
.
If claiming a child in school between the ages of 18 and 23, a completed VA Form 21-674, Request for
Approval of School Attendance;
If claiming benefits for a seriously disabled child, all, if any, relevant, private medical treatment
records for the child's pertinent disabilities.
3. Report for any VA medical examinations VA determines are necessary to decide your claim.
SUPERSEDES VA FORM 21P-527EZ, APR 2016,
Page 1
21P-527EZ
VA FORM
WHICH WILL NOT BE USED.
OCT 2018
NOTICE TO VETERAN OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR
VETERANS PENSION BENEFITS
(This notice is applicable to veterans claims for: Veterans Pension (a needs based benefit) • Special Monthly Pension • Benefits
Based on a Veteran's Seriously Disabled Child)
Use this notice and the attached application to submit a claim for veterans pension.
This notice informs you of the evidence necessary to substantiate your claim.
Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and
there is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans pension, simply submit your
claim in accordance with the "FDC Criteria" shown below. If you are making a claim for veterans disability compensation or related
compensation benefits, use VA Form 21-526EZ, Application for Disability
Compensation and Related Compensation Benefits. If you are making a claim for survivor benefits, use
VA Form 21P-534EZ, Application for DIC, Survivors Pension, and/or Accrued Benefits.
VA forms are available at www.va.gov/vaforms.
FDC Criteria (Claim(s) for Veterans Pension Benefits
1. Submit your claim on a signed and completed VA Form 21P-527EZ, Application for Veterans Pension (attached).
.
2. Submit simultaneously with your claim:
.
All necessary income and asset information; AND
All, if any, relevant, private medical treatment records and an identification of any relevant
treatment records available at a Federal facility, such as a VA medical center.
Note: Read the Important note below and attach current medical evidence showing that you are permanently and totally
disabled, if necessary.
IMPORTANT: If you are a veteran who is claiming pension and you are age 65 or older, or determined to be disabled
by the Social Security Administration, you DO NOT have to submit medical evidence with your application unless you
are claiming special monthly pension. Special monthly pension is an increased amount paid to individuals who, due to
mental or physical disability, require the aid of another person to perform activities of daily living, are a patient in a
nursing home, have severe visual problems, or are substantially confined to his or her home.
Special Circumstances
Under the special circumstances shown below, you must also submit simultaneously with your claim:
.
If claiming veterans pension with special monthly pension, a completed VA Form 21-2680, Examination
for Housebound Status or Permanent Need for Regular Aid and Attendance, or (if a patient in a nursing home)
.
a completed VA Form 21-0779, Request for Nursing Home Information in Connection with Claim for Aid
and Attendance;
.
If claiming a child in school between the ages of 18 and 23, a completed VA Form 21-674, Request for
Approval of School Attendance;
If claiming benefits for a seriously disabled child, all, if any, relevant, private medical treatment
records for the child's pertinent disabilities.
3. Report for any VA medical examinations VA determines are necessary to decide your claim.
SUPERSEDES VA FORM 21P-527EZ, APR 2016,
Page 1
21P-527EZ
VA FORM
WHICH WILL NOT BE USED.
OCT 2018
The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!
Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are
entitled. If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your
claim, then VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard
Claim Process. See below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional
Expedited Process). If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim
Process.
WHAT YOU NEED TO DO
You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant
evidence not in your possession.
FDC Program (Optional Expedited Process)
Standard Claim Process
You must:
You must:
• If you know of evidence not in your possession and want
• Submit your claim in accordance with the
"FDC Criteria" (see page 1)
VA to try to get it for you, give VA enough information
about the evidence so that we can request it from the
person or agency that has it
If the holder of the evidence declines to give it to VA, asks for a
fee to provide it, or otherwise cannot get the evidence, VA will
notify you and provide you with an opportunity to submit the
information or evidence. It is your responsibility to make sure
we receive all requested records that are not in the possession
of a Federal department or agency.
HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM
FDC Program (Optional Expedited Process)
Standard Claim Process
VA will:
VA will:
• Retrieve relevant records from a Federal facility, such as
• Retrieve relevant records from a Federal facility such as
a VA medical center, that you adequately identify and
a VA medical center, that you adequately identify and
authorize VA to obtain
authorize VA to obtain
• Provide a medical examination for you, or get a medical
• Provide a medical examination for you, or get a medical
opinion, if we determine it is necessary to decide your
opinion, if we determine it is necessary to decide your
claim
claim
• Make every reasonable effort to obtain relevant
records not held by a Federal facility that you adequately
identify and authorize VA to obtain. These may include
records from State or local governments and privately
held evidence and information you tell us about, such as
private doctor or hospital records or records from current
or former employers
WHEN YOU SHOULD SEND WHAT WE NEED
FDC Program (Optional Expedited Process)
Standard Claim Process
You must:
You are strongly encouraged to:
• Send the information and evidence simultaneously with
• Send any information or evidence as soon as you can
your claim
If you submit additional information or evidence after you
You have up to one year from the date we receive the claim to
submit your "fully developed" claim, then VA will remove the
submit the information and evidence necessary to support your
claim from the FDC Program Expedited Process and process
claim. If we decide the claim before one year from the date we
it in the Standard Claim Process. If we decide your claim before
receive the claim, you will still have the remainder of the one
one year from the date we receive the claim, you will still have
year period to submit additional information or evidence
the remainder of the one-year period to submit additional
necessary to support the claim.
information or evidence necessary to support the claim.
Page 2
VA FORM 21P-527EZ, OCT 2018
WHERE TO SEND INFORMATION AND EVIDENCE
When you have completed this application, mail or fax it to the appropriate Pension Center listed on Page 10. Be sure to attach any
materials that support and explain your claim. Also, make a photocopy of your application and all supporting material you submit to
VA before mailing or faxing it.
WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM
If you are claiming...
See the evidence table titled...
Veterans Pension (a needs-based benefit)
Veterans Pension
Special Monthly Pension
Veterans Pension with Special Monthly Pension
Benefits because your child is severely disabled
Child Incapable of self-support
EVIDENCE TABLES
Veterans Pension
To support a claim for veterans pension, the evidence must show:
1. You met certain minimum active service requirements during a period of war.
Generally, those requirements are:
• 90 days of service during a period of war; OR
• 90 days of consecutive service at least one day of which was during a period of war; OR
• 90 days of combined service during more than one period of war:
(Note: If your service began after September 7, 1980, additional length of service requirements may apply, typically
requiring two years of continuous service or completion of active-duty obligation)
• OR, any length of active service during a period of war with a discharge due to a service-connected disability
2. You are age 65 or older or are permanently and totally disabled. Your disability or disabilities do not have to be related
to your military service. You are considered permanently and totally disabled if medical evidence shows you are:
• A patient in a nursing home for long-term care or medical foster home; OR
• Receiving Social Security disability benefits; OR
• Unemployable due to a disability reasonably certain to continue throughout your lifetime; OR
• Suffering from a disability that is reasonably certain to continue throughout your lifetime that would make it
impossible for an average person to follow a substantially gainful occupation; OR
• Suffering from a disease or disorder that VA determines causes persons who have that disease or disorder
to be permanently and totally disabled
3. Your income and assets are within established limits. 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 (unless custody has been legally removed by a court and you do not contribute to your child's support
or the child's income is not reasonably available to you).
Assets means the fair market value of all property that an individual owns, including all real and personal property
(excluding the value of the 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.
Page 3
VA FORM 21P-527EZ, OCT 2018
EVIDENCE TABLES (Continued)
Veterans Pension with Special Monthly Pension
To support a claim for increased pension eligibility based on the need for aid and attendance, the evidence must show:
• You have corrected visual acuity of 5/200 or less in both eyes; OR
• You have concentric contraction of the visual field to 5 degrees or less; OR
• You are a patient in a nursing home due to mental or physical incapacity; OR
• You need the aid of another person to perform activities of daily living (ADLs), such as bathing or showering,
dressing, eating, toileting, and transferring (e.g. getting in and out of bed); OR
• You require regular supervision because you are unsafe if you are left alone due to a mental disorder, OR
• You are bedridden, in that your disability requires that you remain in bed apart from any prescribed course
of convalescence or treatment.
To support your claim for increased pension eligibility based on being housebound, the evidence must show:
• You have a single permanent disability evaluated as 100 percent disabling; AND due to such disability, you are
permanently and substantially confined to your immediate premises; OR
• You have a single permanent disability evaluated as 100 percent disabled, AND you have an additional disability or
disabilities rated 60 percent or higher.
Child Incapable of Self-Support
To support a claim for benefits based on a veteran's child being incapable of self-support, the evidence must show that the child,
before his or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.
IMPORTANT
If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you
and/or your spouse resided at the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later
date when you became eligible for benefits) (38 U.S.C. § 103(c)). Additional guidance on when VA recognized marriages is
available at http://www.va.gov/opa/marriage/.
How VA Determines the Effective Date
If we grant your claim, the beginning date of your entitlement will generally be based on when we received your claim.
Special monthly pension may be assigned for disabilities that affect your ability to perform certain activities of daily living
or the ability to leave your home. Special monthly pension may be effective from the date the medical evidence first shows
entitlement.
For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/.
For more information on VA benefits, visit our web site at www.va.gov, contact us at https://iris.custhelp.com, 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.
IMPORTANT
If you wish to make a claim for veterans disability compensation and/or related compensation benefits, use VA Form 21-526EZ,
Application for Disability Compensation and Related Compensation Benefits. VA forms are available at www.va.gov/vaforms. If you
cannot access this form, write the words "Will claim compensation - send VA Form 21-526EZ" in Item 8 or at the top of the attached
application and VA will send you the form.
VA FORM 21P-527EZ, OCT 2018
Page 4
OMB Control No. 2900-0002
Respondent Burden: 25 minutes
Expiration Date: 10/31/2021
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
APPLICATION FOR VETERANS PENSION
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 9 before completing the form.
SECTION I: VETERAN'S PERSONAL INFORMATION
(MUST COMPLETE)
1. VETERAN'S NAME (Last, First, Middle)
2. SOCIAL SECURITY NUMBER
3. DATE OF BIRTH (MM,DD,YYYY)
5. VA FILE NUMBER
4. HAVE YOU EVER FILED A CLAIM WITH VA?
YES
NO
(If "Yes," provide your file number in Item 5)
6A. MAILING ADDRESS
6B. TELEPHONE NUMBERS (Include Area Code)
DAYTIME
(
)
Street address, rural route, or P.O. Box
Apt. number
EVENING
(
)
CELL PHONE
City
State
ZIP Code
Country
(
)
7A. PREFERRED E-MAIL ADDRESS (If applicable)
7B. ALTERNATE E-MAIL ADDRESS (If applicable)
8. WHAT DISABILITY(IES) PREVENTS YOU FROM WORKING?
A. DISABILITY(IES)
B. DATE DISABILITY(IES) BEGAN
9. LIST ANY VA MEDICAL CENTERS WHERE YOU RECEIVED TREATMENT FOR YOUR
CLAIMED DISABILITY(IES) AND PROVIDE TREATMENT DATES
B. DATE(S) OF TREATMENT
A. NAME AND LOCATION OF VA MEDICAL CENTER
SECTION II: VETERAN'S SERVICE INFORMATION
(MUST COMPLETE)
10A. DID YOU SERVE UNDER ANOTHER NAME?
10B. PLEASE LIST THE OTHER NAME(S) YOU SERVED UNDER
YES
(If "Yes," complete Item 10B)
NO
(If "No," skip to Item 11A)
11B. BRANCH OF SERVICE
11C. RELEASE DATE FROM ACTIVE SERVICE
11A. I ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
11E. PLACE OF LAST SEPARATION
11D. SERVICE NUMBER
12A. HAVE YOU EVER BEEN A PRISONER OF WAR?
12B. DATES OF CONFINEMENT ON (MM,DD,YYYY)
YES
NO
(If "No," skip to Item 13A)
(If "Yes," complete Item 12B)
To:
From:
SECTION III: VETERAN'S DISABILITY(IES) AND BACKGROUND
)
(MUST COMPLETE
NOTE: You do not have to submit medical evidence or list disabilities if you are age 65 or older, unless you are housebound, or require the regular
assistance of another person.
13B. WHEN DID THE DISABILITY(IES) BEGIN? (MM, DD, YYYY)
13A. WHAT DISABILITY(IES) PREVENT YOU FROM WORKING?
14A. ARE YOU CLAIMING SPECIAL MONTHLY PENSION BECAUSE YOU NEED
14B. ARE YOU NOW OR HAVE YOU RECENTLY BEEN HOSPITALIZED OR
THE REGULAR ASSISTANCE OF ANOTHER PERSON, HAVE SEVERE VISUAL
GIVEN OUTPATIENT OR HOME CARE DUE TO THE DISABILITY(IES) LISTED
PROBLEMS, OR ARE GENERALLY CONFINED TO YOUR IMMEDIATE PREMISES?
IN ITEM 13A?
(If "Yes," complete and attach with this application, VA Form
YES
NO
YES
NO
21-2680, Exam for Housebound Status or Permanent Need
for Regular Aid and Attendance. Please make sure every box
is complete and signed by a Physician, Physician Assistant
(PA), Certified Nurse Practitioner (CNP), or Clinical Nurse
Specialist (CNS.))
15B. NAME AND MAILING ADDRESS OF FACILITY OR DOCTOR
15A. DATE(S) OF RECENT HOSPITALIZATION OR CARE
SUPERSEDES VA FORM 21P-527EZ, APR 2016,
Page 5
VA FORM
21P-527EZ
WHICH WILL NOT BE USED.
OCT 2018
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