VA Form 21P-0514-1 DIC Eligibility Verification Report

OMB Approved No. 2900-0101
Respondent Burden: 30 Minutes
Expiration Date: xx/xx/xxxx
FIRST, MIDDLE, LAST NAME OF VETERAN

DIC PARENT'S ELIGIBILITY
VERIFICATION REPORT

VETERAN'S SOCIAL SECURITY NUMBER

FIRST, MIDDLE, LAST NAME OF PARENT

VA FILE NUMBER - PAYEE NUMBER - STUB NAME

COMPLETE ADDRESS OF PARENT

VA REGIONAL OFFICE RETURN ADDRESS

4

IMPORTANT - Please read the enclosed EVR Instructions (VA Form 21P-0510) prior to completing this form.
1A. YOUR SOCIAL SECURITY NUMBER

1B. YOUR SPOUSE'S SOCIAL SECURITY NUMBER

1C. YOUR DATE OF BIRTH (Mo., day, year)

1D. YOUR SPOUSE'S DATE OF BIRTH (Mo., day, year)

2. MARITAL STATUS (Check only one box)
MARRIED - LIVING WITH OTHER PARENT OF VETERAN (You are currently married and live with the veteran's other parent

(1)

or you live apart only for medical reasons.)
MARRIED - LIVING WITH SPOUSE WHO IS NOT OTHER PARENT OF VETERAN (You are currently married to a person who

(2)

is not the veteran's other parent and you live together or live apart only for medical reasons.)
SEPARATED FROM SPOUSE (You are married but estranged from your spouse.) If you are separated within the last 12 months,

(3)

show the date of separation

.

NOT NOW MARRIED (You have never married or are now divorced or widowed.) If your most recent marriage ended during the

(4)

last 12 months, enter the date of divorce or the date of your spouse's death.
Date of spouse's death

Date of divorce
3. IS THE OTHER PARENT OF THE VETERAN LIVING?
YES

NO

UNKNOWN

4A. ARE YOU A PATIENT IN A NURSING HOME?
YES

NO (If "Yes," complete Items 4B and 4C. If "No," go to Item 5)

4C. ENTER THE NAME, COMPLETE ADDRESS, AND
TELEPHONE NUMBER OF THE NURSING HOME (Please

include ZIP Code)

4B. SHOW THE DATE YOU ENTERED THE NURSING HOME

5. WERE YOU OR YOUR SPOUSE EMPLOYED AT ANY TIME DURING THE 12
MONTH PERIOD PRECEDING THE DATE YOU SIGNED THE FORM?
YES

NO

6. DO YOU RECEIVE ANY OTHER VA BENEFITS AS A VETERAN, PARENT, OR SURVIVING SPOUSE?
YES
VA FORM
xxx xxxx

NO

(If "Yes," write in the VA file number of the other benefit)

21P-0514-1

SUPERSEDES VA FORM 21-0514-1, APR 2015,
WHICH WILL NOT BE USED.

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7A. MONTHLY INCOME (Read Paragraphs 2 and 3 of the EVR instructions)
GROSS MONTHLY AMOUNTS (If no income was received from a particular source, write "0" or "none." VA WILL INTERPRET A BLANK SPACE AS "NONE or "0." )

YOU

SOURCE
SOCIAL SECURITY

YOUR SPOUSE
$

$

U.S. CIVIL SERVICE
U.S. RAILROAD RETIREMENT
BLACK LUNG BENEFITS
MILITARY RETIREMENT
OTHER (Show Source)

OTHER (Show Source)
7B. ANNUAL INCOME (Read Paragraphs 2 and 4 of the EVR Instructions)
If no income was received from a particular source, write "0" or "none." VA WILL INTERPRET A BLANK SPACE AS "NONE" or "0."
YOU
SOURCE
GROSS WAGES FROM
ALL EMPLOYMENT

YOUR SPOUSE

FROM:

FROM:

FROM:

FROM:

THRU:

THRU:

THRU:

THRU:

$

$

TOTAL INTEREST AND
DIVIDENDS
ALL OTHER

(Show Source)
ALL OTHER

(Show Source)
7C. DID ANY INCOME CHANGE (Increase/Decrease) DURING THE PAST 12 MONTHS? (Answer "NO" if there were no income changes or if the only

change was a Social Security/VA cost of living adjustment. Answer "YES" if there were any other income changes or if you received any NEW
source of income or any ONE-TIME income)
YES

NO

(If "Yes," complete Items 7D through 7F. If "No," go to Item 8)

7D. WHAT INCOME CHANGED?

(Show what income changed; for
example, wages, city pension, etc.)

7E. WHEN DID THE INCOME CHANGE?

(Show the dates you received any new
income or the date income changed)

7F. HOW DID INCOME CHANGE?

(Explain what happened; for example, quit
work, got raise, received inheritance)

8. MEDICAL EXPENSES (Read Paragraph 6 of the EVR Instructions)

Normally, medical expenses are reported at the end of the year. If you are using this form as your annual Eligibility Verification Report
and Paragraph 6 of the EVR Instructions indicates that you should report medical expenses, use VA Form 21P-8416, Medical Expense
Report, to report your medical expenses. If you are using this form as a supplement to a pending claim, you do not need to report medical
expenses. If entitlement is established, you will have an opportunity to report your medical expenses at the end of the year.
9A. SIGNATURE OF PARENT (Read paragraph 9 of the EVR Instructions before signing)

9B. DATE SIGNED

9C. TELEPHONE NUMBERS (Include Area Code)
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 21P-0514-1, xxx xxxx

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