Form VA Form 21-0784 VA Form 21-0784 Supplemental Income Questionnaire (For Philippine Claims

OMB Control No. 2900-0668
Respondent Burden: 15 Minutes
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

SUPPLEMENTAL INCOME
QUESTIONNAIRE
(For Philippine Claims Only)
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 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,
Compensation, Pension, Education, and Rehabilitation 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 pension benefits (38 U.S.C. 1521, 1541, and 1542).
Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15 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
http;//www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.

INSTRUCTIONS: Before further action can be taken on your claim for pension, we need more information about your income from other sources. Your answer to
every question is important to help us complete your claim. Please answer all questions fully and accurately, and print clearly. If an answer is "none" or "0," write that.
Do not leave any questions blank. Specify whether amounts are in dollars or pesos.
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

2. VA FILE NUMBER

3. FIRST - MIDDLE - LAST NAME OF CLAIMANT
(If other than veteran)

PART I - SOURCES OF INCOME
NOTE: Be sure to report in Part II the amounts of income received for any items marked "YES."
DO YOU OR YOUR DEPENDENTS:

YES

NO

4. OPERATE A SARI-SARI STORE?
5. ENGAGE IN A BUY-AND-SELL BUSINESS?
6. OWN A FISHING BOAT?
7. IF YOU ANSWERED "YES" TO ITEM 6, DO YOU OR YOUR DEPENDENTS:
A. SELL PART OF THE CATCH?
B. RECEIVE PART OF THE CATCH AS RENT?
8. OWN FARM LANDS AND SELL THE PRODUCE, FRUITS, VEGETABLES, RICE, CORN, COCONUT, NIPA, BURI RATTAN,
BAMBOO, ANIMALS, ETC.?
9. IF YOU ANSWERED "YES" TO ITEM 8, DO YOU OR YOUR DEPENDENTS:
A. RECEIVE CASH FOR YOUR SHARE OF THE PRODUCE?
B. RECEIVE PART OF THE CROP AS YOUR SHARE?
10. RENT OUT ANY PART OF YOUR HOME OR APARTMENT?
11. OWN STOCKS?
12. HAVE A SAVINGS ACCOUNT?
13. HAVE SAVINGS CERTIFICATES?
14. HAVE GOVERNMENT (TREASURY) BONDS?

PART II - INCOME RECEIVED DURING THE LAST 12 MONTHS
MONTHLY INCOME (Tell us the income you and your dependents receive every month.)
SOURCES OF INCOME

VETERAN

SPOUSE
OR
WIDOW

CHILD

CHILD

15. U.S. SOCIAL SECURITY
16. U.S. CIVIL SERVICE
17. MILITARY RETIRED PAY/SURVIVORS BENEFIT PLAN ANNUITY (SBP)
18. OTHER RETIREMENT BENEFITS (Please write in the source below, i.e.,
Philippine Government Retirement, GSIS Retirement, Philippine Social Security,
PVAO Annuities)
A.
B.
C.
D.

OTHER INCOME (Tell us about other income you and your dependents receive.)
19. GROSS WAGES AND SALARY
20. TOTAL INTEREST AND DIVIDENDS RECEIVED ON SAVINGS ACCOUNTS,
TIME DEPOSITS, STOCKS, AND BONDS, ETC.
21. INCOME FROM RENTAL OF HOUSE OR APARTMENT
22. INCOME FROM RENTAL OF FARM OR RICE LAND (Give the peso equivalent
of farm products received)
VA FORM
JUN 2005

21-0784

(Continued on Reverse)

OTHER INCOME (Tell us about other income you and your dependents receive.) (Continued)
SOURCES OF INCOME

VETERAN

SPOUSE
OR
WIDOW

CHILD

CHILD

SPOUSE
OR
WIDOW

CHILD

CHILD

23. INCOME FROM FARM (Please write in the type of products below, i.e., palay,
corn, coconut, copra, coffee, fruits, vegetables, etc., and give the peso equivalent
of farm products generated)

24. INCOME FROM BUSINESS
25. CONTRIBUTIONS FROM CHILDREN WHO ARE NOT YOUR DEPENDENTS
26. OTHER INCOME (Please write in the source below)

27. OTHER INCOME (Please write in the source below)

PART III - NET WORTH
SOURCE

VETERAN

28. CASH, BANK SAVINGS ACCOUNTS
29. TIME DEPOSITS IN BANK
30. STOCKS AND BONDS
31. VALUE OF BUSINESS ASSETS AND INVESTMENTS
32. MARKET VALUE OF FARM
33. MARKET VALUE OF APARTMENT AND OTHER PROPERTIES
(Not your home unless part of it is rented)
34. REMARKS

CERTIFICATION
I CERTIFY THAT the statements in this document are true and complete to the best of my knowledge.
35A. SIGNATURE OF CLAIMANT (If claimant can write, then he or she must sign the name. If claimant cannot write then affix thumbprint which must be
witnessed by two persons who can write)

35B. TODAY’S DATE

WITNESSES TO SIGNATURE IF MADE BY THUMBPRINT
36A. SIGNATURE OF WITNESS (If claimant signed above by thumbprint)

37A. SIGNATURE OF WITNESS (If claimant signed above by thumbprint)

36B. PRINT NAME AND ADDRESS OF WITNESS

37B. PRINT NAME AND ADDRESS OF WITNESS

38. PRINT NAME AND ADDRESS OF PERSON WHO HELPED YOU COMPLETE THIS FORM (If applicable)

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 to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM 21-0784, JUN 2005