Form VA Form 21P-4185 VA Form 21P-4185 Report of Income from Property or Business

OMB Control No. 2900-0108
Respondent Burden: 30 Minutes
Expiration Date: 02/28/2018

REPORT OF INCOME FROM PROPERTY OR BUSINESS
Privacy Act Notice: The 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, 58VA21/22/28, Compensation,
Pension, Education, and Vocational Rehabilitation and Employment 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 benefits (38 U.S.C. 1315 and 1506). Title 38, United States Code, 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 numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.
INSTRUCTIONS: Please provide specific information about the gross income and expenses of your property and/or business, so we can determine eligibility for
benefits. Print all answers clearly. If an answer is "none" or "0," write that or line through the space provided. For additional space, attach a separate sheet, indicating
the item number to which the answers apply. Make sure to write the veteran's name and VA claim number on any attachments to the form.
Rental income: Net rental income is gross rental income less expenses. Depreciation and payments on the principal of a mortgage are not deductible. If the rental
property is partially occupied by the owner, report the gross income received and the proportionate part of the expenses. For example: If you own a two-family house
that is occupied by you and another family, report the gross income you receive from the other family and one-half of the expenses.
Business income: Net business income is gross income less operating expenses. Depreciation, withdrawals of cash or merchandise, and salaries paid you or your
partners are not deductible. Deductible operating expenses include cost of goods sold, rent, normal repairs, taxes (other than Federal income tax), salary or wages of
employees, insurance, interest on business debts, and similar expenses.
1. FIRST NAME-MIDDLE NAME-LAST NAME OF VETERAN

2. VA FILE NUMBER

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

4. MAILING ADDRESS OF CLAIMANT (Number and street or rural route or P.O. Box, city, State and ZIP Code)

5. WHAT PORTION OF RENTAL
PROPERTY, IF ANY, IS OCCUPIED
BY CLAIMANT?

6. ADDRESS OF RENTAL PROPERTY

7. BRIEF DESCRIPTION OF RENTAL PROPERTY (Include number and type
of units)

8. ADDRESS OF BUSINESS

9. TYPE OR NATURE OF BUSINESS

STOCK INVENTORY
OF BUSINESS
LINE
NO.

10A. VALUE AT BEGINNING OF CURRENT CALENDAR 10B. VALUE AT END OF CURRENT CALENDAR YEAR
YEAR

$

(11A)
TOTAL EXPENSES RELATING TO RENTAL PROPERTY OR
OPERATION OF BUSINESS
NOTE: Do not list personal expenditures.

1

TAXES

2

UTILITIES (If furnished)

3

INSURANCE

4

INTEREST ON MORTGAGE

5

FUEL (If furnished)

6

NORMAL REPAIRS

7

COST OF GOODS SOLD

8

RENT

9

EMPLOYEES' SALARIES

VA FORM
XXX XXXX

$

21P-4185

(11B)
EXPENSES FOR THE PERIOD
FROM
THRU
(If no dates are shown, report
expenses for last calendar year)

$

SUPERSEDES VA FORM 21-4185, FEB 2015, WHICH
WILL NOT BE USED.

(11C)
EXPENSES FOR THE PERIOD
FROM
THRU
(If no dates are shown, report
expenses for current calendar year)

$

Page 1

10

INTEREST ON BUSINESS DEBT

11

OTHER (Explain briefly in Item 13, "Remarks" )

12

TOTAL EXPENSES

$

$

IMPORTANT: Report total gross income in Line 1, total expenses in Line 2, and total net income in Line 3. If the property or
business is owned jointly, report your share of the net income in Line 4 and your fractional share of property ownership in Line 5. List
the name(s), address(es), and fractional share(s) of ownership for all remaining owner(s) in Line 6. If your spouse and/or dependent
child(ren) are joint owners, report their net property or business income in Item 13, " Remarks."
(12B)
EXPENSES FOR THE PERIOD
FROM
THRU

(12C)
EXPENSES FOR THE PERIOD
FROM
THRU

LINE
NO.

(12A)
GROSS INCOME, TOTAL EXPENSES, AND NET INCOME
FROM PROPERTY OR BUSINESS

1

GROSS INCOME FROM RENTAL PROPERTY AND BUSINESS

$

$

2

TOTAL EXPENSES (Enter total from line 12, above)

$

$

3

NET INCOME FROM RENTAL PROPERTY OR RECEIPTS
FROM BUSINESS (Subtract line 2 from line 1)

$

$

4

CLAIMANT'S SHARE OF NET INCOME FROM RENTAL
PROPERTY OR RECEIPTS FROM BUSINESS

$

5

SHARE OF PROPERTY OR BUSINESS OWNED BY
CLAIMANT (Fractional)

(If no dates are shown, report expenses
(If no dates are shown, report
for last calendar year)
expenses for current calendar year)

NOTE: Complete Items 4, 5, and 6 only if property or business is owned jointly.
$

LIST THE NAME(S), ADDRESS(ES), AND FRACTIONAL SHARES(S) OF OWNERSHIP FOR ALL REMAINING OWNERS

6
13. REMARKS

I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge.
14A. SIGNATURE OF CLAIMANT

15A. DAYTIME TELEPHONE NUMBER (Including Area Code)

14B. DATE

15B. EVENING TELEPHONE NUMBER (Including Area Code)

WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK: Signature made by mark must be witnessed by two
persons who know the claimant personally, and the signatures and addresses of such witnesses must be shown below.
16A. SIGNATURE OF WITNESS

16B. PRINTED NAME AND ADDRESS OF WITNESS

17A. SIGNATURE OF WITNESS

17B. PRINTED NAME AND ADDRESS OF WITNESS

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement of a material
fact knowing it to be false.
VA FORM 21P-4185, XXX XXXX

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