Form 21-0161A Income Verification

In Reply Refer To:

.

Adjudication Officer (21)
VA Regional Office

Dear Employer,
The Department of Veterans Affairs (VA) recently reviewed its records of individuals who are receiving
VA benefits in which employment and wages are entitlement factors. Your employee, identified on the
form printed on the reverse of this letter, was shown as having been employed in some capacity and paid
wages by your firm during calendar year
.
Federal law requires separate verification of this information before we adjust a beneficary’s
income-dependent benefits in connection with the administration of veterans benefits under Title 38,
U.S.C.
Please determine whether the individual actually worked for you or your firm. If so, please record the
total (gross) wages paid to this employee, for the calendar years indicated, and enter the remaining
requested information in the appropriate spaces on the reverse of this letter. If you are unable to
complete the form, please note that fact along with a brief explanation of the reason(s) for
noncompletion in Item 8, the "Remarks" section of the form. The information you provide will be used
for official purposes only. Correspondence concerning this request should be addressed as shown in the
"In Reply Refer To:" address area above. In Item 9, please enter the mailing address we should use if we
have further need to contact your office.

We appreciate your cooperation in handling this matter expeditiously. When the form is completed,
please have this letter and any continuation sheet(s) inserted into the enclosed business reply envelope so
that the "In Reply Refer To:" address area is clearly visible in the window of the envelope. No postage
is required for mailing your response to us.
Sincerely yours,

Under Secretary for Benefits
Enclosure

VA FORM
JUN 2006

21-0161a

OMB Control No. 2900-0518
Respondent Burden: 30 minutes

1. REGIONAL OFFICE OF RECORD

INCOME VERIFICATION
2. NAME OF INCOME RECIPIENT

3. INCOME RECIPIENT’S SOCIAL SECURITY NO.

4. VA FILE NUMBER

5. DATE OF FIRST INCOME PAYMENT

6A. IS THE RECIPIENT CURRENTLY RECEIVING PAYMENT?

6B. DATE OF LAST PAYMENT

YES

NO

(If "No," please complete Item 6B)

PRIVACY ACT INFORMATION: 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. Responses are required in
order to obtain or retain benefits. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information to gather information from employers to determine entitlement to incomedependent benefits. Without this information some beneficiaries will be paid at a higher rate than they are entitled to receive. Title
38, United States Code 1506, 1521, and 6102 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 number can be located on the OMB Internet Page at
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.

CALENDAR
YEAR

TYPE OF PAYMENT
(Salary, wages, pension, commissions, etc.)

7A

7B

GROSS ANNUAL
PAYMENTS

WORK BASIS IF EMPLOYEE

7C

7D

(Full-time, Part-time or intermittent)

8.REMARKS

9. NAME AND ADDRESS OF PAYING ENTITY

10. DATE COMPLETED

11. NAME AND SIGNATURE OF PERSON COMPLETING
THIS FORM

12. JOB TITLE OF PERSON COMPLETING THIS FORM

13. TELEPHONE NUMBER OF PERSON COMPLETING THIS
FORM (Include Area Code)