ELIGIBILITY VERIFICATION REPORT INSTRUCTIONS

SUPERSEDES VA FORM 21-0510, JUN 2004, 21-0510 WHICH WILL NOT BE USED. 

NOTE: Read very carefully and keep these instruction sheets for your reference.

The Eligibility Verification Report (EVR) form will refer you to the instruction paragraphs that apply to you. There are specific 

instructions for each type of EVR. You can determine what type of EVR you have by looking at the number in the upper right hand 

corner on the front of this form. This number is next to the form title "Eligibility Verification Report." 

General Information

D. What are aid and attendance and housebound benefits? 

(Continued) 

Pension payments may be reduced to $90 per month if you have 

no dependents and are receiving nursing home care which is 

covered by Medicaid. This reduction only applies if you are 

receiving Improved Pension. The reduction does not apply if 

you receive Parents' Dependency and Indemnity Compensation 

(DIC), Old Law Pension, or Section 306 Pension. You are 

receiving Old Law Pension, or Section 306 Pension if 

entitlement to pension was established before January 1, 1979.

VA may pay a higher rate of benefits to a veteran, surviving 

spouse, or surviving parent who is blind, a patient in a nursing 

home, or otherwise needs regular aid and attendance. VA may 

also pay a higher rate of pension to a veteran who is 

permanently confined to his or her home because of a disability. 

A surviving spouse must be receiving or entitled to receive 

Improved Pension to qualify for a higher rate of pension based 

on being permanently confined to his or her home because of a 

disability. You are receiving Improved Pension if entitlement to 

pension was established on or after January 1, 1979.

You have a right at any time to submit additional information or 

to have a personal hearing to explain or clarify your statements. 

You also have the right to be represented at a hearing by the 

representative of your choice. For more information about 

personal hearings or assigning a representative, contact VA as 

shown in Item A.

If there is a significant increase in your family income or net 

worth, or if there is any change in your marital status or the 

status of your dependents after you return your EVR, notify VA 

immediately. Fully describe the change and furnish your name, 

VA claim number, and Social Security number. Do not wait to 

report the change on next year's EVR. If you do not promptly 

notify us of these changes, this may result in an overpayment in 

your account. 

If you have questions about this form, how to fill it out, or about 

benefits, contact your nearest VA regional office. You can 

locate the address of the nearest regional office in your 

telephone book blue pages under "United States Government, 

Veterans" or call 1-877-294-6380 (for the Hearing Impaired 

TDD line 1-800-829-4833). You may also contact VA by 

Internet at: https://iris.va.gov

B. How do I complete my EVR?

Print all answers clearly. If you must write an answer do so very 

clearly and plainly. If an answer is "none" or "0," write that or 

line through the space provided. Answer all questions unless the 

instructions specifically indicate that the item does not have to 

be answered. 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 EVR.

C. What do I do when I have completed my EVR?

D. What are aid and attendance and housebound benefits?

A. How can I contact VA if I have questions?

If you wish to claim either of these benefits and are not in a 

nursing home, attach a separate sheet of paper stating the 

benefits you are claiming. Also, submit a statement from your 

doctor showing the extent of your disabilities. If you are in a 

nursing home, be sure to complete the items on the EVR 

pertaining to nursing home care and provide the complete 

address and phone number of the nursing home.

G. What if I believe that VA has made an error in 

processing or deciding my benefits? 

Make sure you sign and date the EVR. When you have 

completed the EVR, mail it or take it to the VA address shown 

on the front of the EVR. If no address is shown, mail or take the 

EVR to the nearest VA regional office. Be sure to attach any 

materials that support and explain your claim. Also, make a 

photocopy of your EVR and everything that you submit to VA 

before you mail it.

F. What if my income or dependency information changes 

after I return the EVR?

E. How does receiving Medicaid-covered nursing home 

care affect my pension?

VA FORM Page 1 MAY 2010 
INSTRUCTION PARAGRAPHS

1. NUMBER OF UNMARRIED, DEPENDENT CHILDREN 

 

VA recognizes the veteran's biological children, adopted children, and stepchildren as dependents. But these children must 

be unmarried and: 

 

 • under age 18, or 

 • between 18 and 23 and pursuing an approved course of education, or 

 • of any age if they became permanently unable to support themselves before reaching age 18. 

 

Report a child living in your household as "in your custody." Report a child who is not living with you as "not in your custody." 

 

If a child between the ages of 18 and 23 who is receiving benefits or has been established as your dependent based on school 

attendance has stopped attending school, show this change on the EVR. If a child (regardless of age or status) has married, this must 

be shown on the EVR also. If a change in a child's school or marital status occurs after you complete the EVR, notify VA 

immediately. 

 

2. INCOME 

 

You are required to report all income unless the instructions in this paragraph specifically indicate that the item does not apply to you. 

If you are not sure about a particular type of income, report it and provide a full explanation of the source of the income. If any income 

does not count, VA will exclude it when computing your income for VA purposes. If you do not receive income from a particular 

source, write "0" or "none" in the space provided. Do not leave the space blank.

 

Report the gross amounts before you take out deductions for taxes, insurance, etc. 

 

EXAMPLE: Your monthly Civil Service check is $365.60. The deduction for taxes is $15. The deduction for health insurance is 

$19.40. 

Do report: Do NOT report:

VA pension that you receive under another claim 

number. Report as "other" monthly income.

VA pension that you receive under 

this claim number.

VA compensation that you receive under this or 

another claim number. Report as "other" monthly income.

Any income you or your dependents received before 

the effective date of your award of benefits, if the 

effective date is during the first year shown on your EVR 

form.

SSI benefits unless you receive Old Law 

Pension (fixed rate of pension since 1960). 

Type 6, 7, 8, 9C, 9S EVRs only: all income received by 

each child. If each of your children has exactly the same 

income and your EVR has a space for reporting a child's 

income, you may write "all" at the top of the child income 

column on the EVR. 

VA education benefits. Report as "other" annual income.

Type 6, 7, 8, 9C, 9S EVRs only: VA insurance benefits. 

Report as "other" annual income.

Type 2S, 2V, 3 EVRs only: If you receive Old Law 

Pension (fixed rate of pension since 1960), 

report Supplemental Security Income (SSI) benefits.

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$365.60 Check Amount 

15.00 Deduction for Taxes 

+19.40 Deduction for Insurance

Amount to report on EVR $400.00
INSTRUCTION PARAGRAPHS (Continued) 

Net worth is the market value of all interest and rights you have in any kind of property less any mortgages or other claims against the 

property. However, net worth does not include the house you live in or a reasonable area of land it sits on. Net worth also does not 

include the value of personal things you use everyday like your vehicle, clothing, and furniture. If property is owned jointly by 

yourself and your spouse, report one-half of the total value held jointly for each of you. 

 

Type 2S, 2V, 3 EVRs: Report your net worth only if you receive Section 306 Pension (fixed rate of pension since 1978). Do not 

report the net worth of your spouse.

 

Type 6, 7, 8, 9S EVRs: You must report net worth for yourself and all dependents for whom you are receiving benefits. 

Report under "annual income:"

Gross monthly amount of income you receive such as 

government, retirement or annuity checks.

Report under "monthly income:"

Annual interest and dividends. This includes but is not 

limited to interest on savings accounts, checking 

accounts, certificates of deposit, mutual funds, and VA 

insurance.

All other income that is not shown in another section 

(for example, VA education benefits, rental income, 

insurance, net income from the operation of a business, 

unemployment compensation, IRA distributions, gifts, 

inheritances, gambling winnings, etc.) 

Gross annual wages from employment.

5. NET WORTH

If you are not sure whether to report income as "monthly income" or "annual income," don't worry. You may report it in either 

category. The important thing is to report all income, clearly state its source, and not to report the same income twice on the EVR. 

2. INCOME (Continued) 

3. MONTHLY INCOME 

Social Security benefits: VA receives information from the Social Security Administration (SSA) about the rates paid to most 

individuals who receive benefits from both VA and SSA. If an amount is preprinted in the Social Security block on your EVR, it 

came from Social Security records or is based on information you have furnished in the past. The amount shown is the sum of your 

monthly amount and your Medicare premium (if any). See the EXAMPLE under Item 2. If the preprinted amount is correct or is 

within $1 of the correct rate, do not make any entry. If the preprinted amount is wrong by more than $1, cross it out, enter the correct 

amount, and, if possible, attach to your EVR an award letter or other notice from SSA showing your correct rate. If any Social 

Security block does not contain a preprinted amount, enter the applicable Social Security rate or "0," as appropriate.

 

Military retirement: Military retirement means a monthly check from the Army, Navy, Air Force, Coast Guard or Marine Corps and 

is usually based on 20 or 30 years service. Do not report your VA benefits as military retirement. Report VA benefits as "other 

income."

4. ANNUAL INCOME 

Last year column: The income reported for the past year should be the actual amounts of gross income received. Use your W-2 

forms, bank statements, etc. Do not rely on your memory, and do not estimate the amount of income already received. 

 

Next year column: The income you report for the coming year should be your best estimate at this time. If there is a significant 

increase in your income after you complete this EVR, notify VA immediately. DO NOT wait until VA sends you another EVR next 

year.

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6. FAMILY MEDICAL EXPENSES

INSTRUCTION PARAGRAPHS (Continued) 

Type 9C EVR: If you are a child claiming or receiving pension in your own right, report your net worth. If you are claiming or 

receiving pension as the custodian of a child or children, report the child's net worth and your net worth unless you are an institutional 

custodian. If you are also the child's parent, you are married, and you live with your spouse, report your and your spouse's net worth.

Do not include any expenses for which you were or will be reimbursed. Do not report any medical expenses paid before the

effective date of your benefits. 

5. NET WORTH (Continued) 

Family medical expenses actually paid by you may be deductible from your income. Report the amount of unreimbursed medical 

expenses, including the Medicare deduction, you paid for yourself or relatives who are members of your household. Any expenses 

reasonably related to medical or dental care of yourself or dependents (including health insurance premiums) may be allowed as 

medical expenses. If you are not sure whether a particular expense can be allowed, furnish a complete description of the purpose of 

the payment. We will let you know if an expense cannot be allowed.

Note: Do not report medical expenses if your only income is VA pension or SSI. If VA pension or SSI is your only income, please skip to 

paragraph 7 of the instructions. 

Type 4 EVR:

Type 6, 7, 

8, 9C, 9S 

EVR:

If you have income other than VA benefits or SSI, you should report medical expenses. Generally 

your rate of pension will not be increased unless the medical expenses you paid (including Medicare 

premiums) exceed 5 percent of the Maximum Annual Pension Rate (MAPR). Rates are frequently 

changed, so it is not possible to keep this information current in these instructions. You can find out 

what the current MAPR is by contacting your nearest VA regional office at 1-877-294-6380 (Hearing 

Impaired TDD line 1-800-829-4833). 

Do not report medical expenses unless you receive Section 306 Pension and have been notified by VA 

that your pension will be terminated due to excessive income. Note: Allowable medical expenses may be 

used to reduce your countable income; however, these expenses cannot be used to increase the protected 

rate of pension that you receive.

Type 2S, 2V, 

3 EVR:

If you have income other than VA benefits or SSI, you should report medical expenses. Generally your 

rate will not be increased unless the medical expenses you paid (including Medicare premiums) exceed 

5 percent of your countable annual income. Note: If your spouse is the veteran's other parent and you 

live together, your spouse will receive a separate EVR and VA Form 21-8416. You may report all your 

and your spouse's medical expenses on a single VA Form 21-8416 or each parent may report his or her 

medical expenses on separate VA Forms 21-8416. If you paid medical expenses from a joint account, one 

parent can claim all the expenses or you may divide up the expenses. Do not report the same medical 

expenses.

If the amount of medical expenses is not preprinted on your EVR, you must itemize any medical expenses you wish to claim. 

Report unreimbursed medical expenses on VA Form 21-8416, "Medical Expense Report." If you need a copy of this form, 

contact the VA at 1-877-294-6380 (Hearing Impaired TDD line 1-800-829-4833). You may also download the form at 

www.va.gov/vaforms. Note: If your current rate of benefits is based on allowance of a continuing deduction for nursing home fees or 

other recurring medical expenses, you must complete VA Form 21-8416 to confirm that you actually paid these expenses or your 

award will be adjusted retroactively to remove the deduction. This will result in an overpayment in your account and possible 

termination of benefits.

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INSTRUCTION PARAGRAPHS (Continued) 

Type 6, 7, 8, 9C, 9S EVRs: Educational or vocational rehabilitation expenses actually paid by you may be deductible from your 

income. Educational or vocational rehabilitation expenses are amounts paid for courses of education or vocational rehabilitation that 

you are pursuing, including tuition, fees, and materials. Report only your educational expenses. Do not include any expenses for 

which you were or will be reimbursed. Do not report your dependents' expenses.

 

Note: Do not report educational or vocational rehabilitation expenses if you are using the EVR to supplement a pending claim. If 

entitlement is established, you will have an opportunity to report your expenses at the end of the year. 

You may be asked to verify the amounts you actually paid, so keep all receipts or other documentation of payments for at least 3 

years after we make a decision on your medical expense claim. If you are unable to provide documentation of the claimed medical 

expenses when asked to do so by VA, your benefits will be retroactively reduced or terminated.

6. FAMILY MEDICAL EXPENSES (Continued)

IMPORTANT

7. EDUCATIONAL OR VOCATIONAL REHABILITATION EXPENSES 

Report hardship expenses on the EVR only if VA is currently excluding your children's income on the grounds of hardship. If this 

applies to you, show the total expenses for family maintenance expected for the next 12 months. 

 

VA can exclude all or part of a dependent child's income if it is not reasonably available to you or if it would cause hardship to 

consider this income in determining your rate of pension. If VA is not currently excluding your children's income and you feel that it 

should be, you will need to complete VA Form 21-0571, "Application for Exclusion of Children's Income." Contact VA at the address 

shown at the top of the EVR form and we will send you this form. You may also download this form at http://www.va.gov/vaforms/. 

The EVR form must be signed by the payee who is recognized by VA. Normally, this will be the person to whom the monthly check 

is payable. The EVR cannot be signed by another person on behalf of the beneficiary unless that person has been recognized as the 

payee by VA. If you are capable of handling your VA funds but are unable to sign your name, you may sign by "X" mark or 

thumbprint. If you sign by "X" mark or thumbprint, furnish the following statement on a separate sheet which should be attached to 

the EVR: "I hereby certify that the information on this form is true and correct to the best of my knowledge and belief." Place your 

mark or thumbprint under this statement and have it signed by two witnesses who must also print their names and addresses. Be sure 

to write the veteran's name and VA claim number on the attachment.

8. FAMILY MAINTENANCE (Hardship) EXPENSES 

9. SIGNATURE 

If the amount of medical expenses is preprinted on your EVR, write in the total amount of unreimbursed medical expenses you 

actually paid and the amount you expect to pay during the next income reporting year. If the amounts you enter are substantially the 

same as the amount preprinted on the EVR, you may submit the EVR without itemizing your medical expenses on VA Form 21-8416.

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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. Giving us your and your dependents SSN account information is mandatory. 

Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 USC 5101 

(c) (1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required 

by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and 

necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 USC 5701). 

Information submitted is subject to verification through computer matching programs with other agencies.

Respondent Burden: We need this information to verify eligibility for pension or Parents' DIC (38 U.S.C. 1506 and 1315). 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 except for VA Forms 21-0517 and 21-0519S which take an average of 40 

minutes. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Valid OMB 

control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If 

desired, you can call 1-877-294-6380 to get information on where to send comments or suggestions about this form.

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