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Federal forms, ICRs, and supporting documents

OMB control number

Pension Claim Questionnaire for Farm Income (VA Form 21P-4165)

OMB 2900-0095 · VA.

OMB 2900-0095

The VA Form 21P-4165 (Formerly VA Form 21-4165) is used to gather information which is necessary to determine a claimant's countable annual income and available assets related to farm operations. Eligibility to income-based benefits cannot be determined without complete income information.

The latest form for Pension Claim Questionnaire for Farm Income (VA Form 21P-4165) expires 2028-12-31 and can be found here.

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Withdrawn and continue
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 Extension without change of a currently approved collection 1987-08-21
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 Revision of a currently approved collection 1984-07-30
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 No material or nonsubstantive change to a currently approved collection 1981-07-17
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 No material or nonsubstantive change to a currently approved collection 1981-01-29
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 Reinstatement without change of a previously approved collection 1980-05-07
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 Extension without change of a currently approved collection 1975-05-09