VA Form 21-0512v-1 Old Law and Section 306 Eligibility Verification Report (Veteran)

VA Form 21-0512v-1 or the "Old Law And Section 306 Eligibility Verification Report (veteran)" is a form issued by the United States Department of Veterans Affairs.

The form was last revised on June 1, 2004 - an up-to-date fillable PDF VA Form 21-0512v-1 down below or find it on the Veterans Affairs Forms website.

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OMB Approved No. 2900-0101
Respondent Burden: 30 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN
OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
2V
(VETERAN)
YOUR COMPLETE MAILING ADDRESS
VA FILE NUMBER
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 veterans 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 7G, Net Worth,
and Item 8, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1A. YOUR SOCIAL SECURITY NUMBER
1B. YOUR SPOUSES'S SOCIAL SECURITY NUMBER
(Mo., day, yr.)
1C. FIRST NAME - MIDDLE NAME - LAST NAME OF YOUR SPOUSE
1D. YOUR SPOUSE'S DATE OF BIRTH
(Check one box)
2. MARITAL STATUS
(You are legally married and live with your spouse or you live apart only for medical reasons.)
(1)
MARRIED-LIVING WITH SPOUSE
(You are legally married but estranged from your spouse.)
(2)
MARRIED-NOT LIVING WITH SPOUSE
Show the amount you contributed to your spouse's support during the last 12 months $
If you separated within the last 12 months, show the date of separation
(You have never married or are now divorced or widowed.)
(3)
NOT MARRIED
If your marriage ended within the last 12 months, show the date of divorce or death
3A. NUMBER OF UNMARRIED DEPENDENT CHILDREN
3B. AMOUNT CONTRIBUTED DURING PAST 12
(See Paragraph 1 of the EVR Instructions)
MONTHS TO CHILDREN NOT IN YOUR CUSTODY
IN YOUR CUSTODY
NOT IN YOUR CUSTODY
$
(If "YES," Complete Items 4B thru 4D. If "NO," go to Item 5.)
4A. ARE YOU A PATIENT IN A NURSING HOME?
YES
NO
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
4C. ENTER THE NAME, COMPLETE ADDRESS, AND TELEPHONE
(Please include ZIP Code)
NUMBER OF THE NURSING HOME
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?
YES
NO
5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
YES
NO
(If you checked "YES," write in the VA File number of the other benefit)
VA FORM
SUPERSEDES VA FORMS 21-0511V-1, NOV 1996 AND
(Continued on Reverse)
21-0512V-1
JUN 2004
21-0512V-1, MAY 2003, WHICH WILL NOT BE USED.
OMB Approved No. 2900-0101
Respondent Burden: 30 minutes
FIRST, MIDDLE, LAST NAME OF VETERAN
OLD LAW AND SECTION 306 ELIGIBILITY
VERIFICATION REPORT
2V
(VETERAN)
YOUR COMPLETE MAILING ADDRESS
VA FILE NUMBER
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 veterans 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 7G, Net Worth,
and Item 8, Family Medical Expenses. If you receive Section 306 Pension, complete all items.
1A. YOUR SOCIAL SECURITY NUMBER
1B. YOUR SPOUSES'S SOCIAL SECURITY NUMBER
(Mo., day, yr.)
1C. FIRST NAME - MIDDLE NAME - LAST NAME OF YOUR SPOUSE
1D. YOUR SPOUSE'S DATE OF BIRTH
(Check one box)
2. MARITAL STATUS
(You are legally married and live with your spouse or you live apart only for medical reasons.)
(1)
MARRIED-LIVING WITH SPOUSE
(You are legally married but estranged from your spouse.)
(2)
MARRIED-NOT LIVING WITH SPOUSE
Show the amount you contributed to your spouse's support during the last 12 months $
If you separated within the last 12 months, show the date of separation
(You have never married or are now divorced or widowed.)
(3)
NOT MARRIED
If your marriage ended within the last 12 months, show the date of divorce or death
3A. NUMBER OF UNMARRIED DEPENDENT CHILDREN
3B. AMOUNT CONTRIBUTED DURING PAST 12
(See Paragraph 1 of the EVR Instructions)
MONTHS TO CHILDREN NOT IN YOUR CUSTODY
IN YOUR CUSTODY
NOT IN YOUR CUSTODY
$
(If "YES," Complete Items 4B thru 4D. If "NO," go to Item 5.)
4A. ARE YOU A PATIENT IN A NURSING HOME?
YES
NO
4B. SHOW THE DATE YOU ENTERED THE NURSING HOME
4C. ENTER THE NAME, COMPLETE ADDRESS, AND TELEPHONE
(Please include ZIP Code)
NUMBER OF THE NURSING HOME
4D. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING
HOME FEES?
YES
NO
5. DID YOU RECEIVE WAGES OR WERE YOU EMPLOYED AT ANY TIME DURING THE PAST 12 MONTHS?
YES
NO
6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
YES
NO
(If you checked "YES," write in the VA File number of the other benefit)
VA FORM
SUPERSEDES VA FORMS 21-0511V-1, NOV 1996 AND
(Continued on Reverse)
21-0512V-1
JUN 2004
21-0512V-1, MAY 2003, WHICH WILL NOT BE USED.
7. REPORT OF INCOME AND NET WORTH
NOTE - If no income or net worth was received from a particular source, write "0"or "none." DO NOT LEAVE ANY ITEMS BLANK.
Exception: Report your spouse's income only if you receive Section 306 Pension.
(Read Paragraphs 2 and 3 of the EVR Instructions)
A. MONTHLY INCOME
GROSS MONTHLY AMOUNTS
SOURCE
VETERAN
SPOUSE - SECTION 306 ONLY
SOCIAL SECURITY
$
$
U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
MILITARY RETIREMENT
BLACK LUNG BENEFITS
SUPPLEMENTAL SECURITY INCOME
(SSI)/PUBLIC ASSISTANCE
OTHER MONTHLY INCOME
(Show Source)
(Read Paragraphs 2 and 4 of the EVR Instructions)
7B. ANNUAL INCOME
NOTE - If no income was received from a particular source, write "0" or "none." DO NOT LEAVE ANY ITEMS BLANK.
Exception: Report your spouse's income only if you receive Section 306 Pension.
LAST YEAR
THIS YEAR
SOURCE
VETERAN
SPOUSE -Sec. 306 Only
VETERAN
SPOUSE -Sec. 306 Only
GROSS WAGES FROM ALL
$
$
$
$
EMPLOYMENT
TOTAL INTEREST AND DIVIDENDS
ALL OTHER (Show Source)
ALL OTHER (Show Source)
(Answer "NO" if there were no income changes or if the only
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE LAST 12 MONTHS?
change was a Social Security/VA cost-of-living adjustment. Answer "YES" if there were any other income changes of if you received any
NEW source of income or any ONE-TIME income)
(If "YES," complete Items 7D, through 7F. If "NO," go to Item 7G.)
(1)
YES
(2)
NO
7D. WHAT INCOME CHANGED?
7E. WHEN DID THE INCOME CHANGE?
7F. HOW DID INCOME CHANGE?
(Show what income changed; for example,
Show the dates you received any new income
(Explain what happened; for example, quit work,
(
wages, city pension, etc.)
or the date income changed)
got raise, received inheritance)
(Read Paragraph 5 of the EVR Instructions)
7G. VETERAN'S NET WORTH
NOTE: Complete only if you receive Section 306 Pension. Skip to Item 9A if you receive Old Law Pension.
SOURCE
VETERAN
SURVIVING SPOUSE
$
$
CASH/NON-INTEREST BEARING BANK ACCOUNTS
INTEREST BEARING BANK ACCOUNTS
IRAs, KEOGH PLANS, ETC.
STOCKS, BONDS, MUTUAL FUNDS, ETC.
REAL PROPERTY (Not your home)
ALL OTHER PROPERTY
8. FAMILY MEDICAL EXPENSES
NOTE: Skip to Item 9A 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.
9A. SIGNATURE OF CLAIMANT, CUSTODIAN OR GUARDIAN (Read Paragraph 9 of the EVR Instructions before signing)
9B. DATE
(Include Area Code)
10. TELEPHONE NUMBER
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.
VA FORM 21-0512V-1, JUN 2004

Download VA Form 21-0512v-1 Old Law and Section 306 Eligibility Verification Report (Veteran)

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