D. What is special monthly pension?

VA may pay a higher rate of disability pension to a veteran

who is blind, a patient in a nursing home, otherwise needs

regular aid and attendance, or who is permanently

confined to his or her home because of a disability. If you

wish to apply for this benefit, check "Yes" for Item 24.

E. What medical evidence should I submit?

Furnish current medical evidence showing that you are

permanently and totally disabled.

Note: If you are age 65 or older or determined to be

disabled by the Social Security Administration, you do not

have to submit medical evidence with your application

unless you are claiming special monthly pension.

If you wish to claim special monthly pension and are not

in a nursing home, furnish a statement from your doctor

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

nursing home, attach a statement signed by an official of

the nursing home showing the date you were admitted to

the nursing home, the level of care you receive, and

whether Medicaid covers all or part of your nursing home

costs.

If you want help getting existing medical records, you

may complete VA Form 21-4142, Authorization and

Consent to Release Information to the Department of

Veterans Affairs (VA). By signing VA Form 21-4142, you

authorize any doctors, hospitals, or caregivers that have

treated you to release information about your treatment to

VA. You do not need to complete this form for any

treatment you received at a VA facility. If you need a copy

of this form, you may contact VA as shown under Item A,

or download the form from our website at

http://www.va.gov/vaforms/.

F. How do I complete my application?

Print all answers clearly. If you must write the answers do

so very clearly and plainly. If an answer is "none" or "0,"

write that. Your answer to every question is important to

help us complete your claim. If you do not know the

answer, write "unknown." For additional space, use Item

42, "Remarks," or attach a separate sheet, indicating the

item number to which the answers apply. Make sure you

sign and date this application (Items 38 and 39).

EXISTING STOCKS OF VA FORM 21-527, General Instructions Page 1

FEB 1999, WILL BE USED. 21-527 VA FORMJUN 2004

Benefits may only be paid from the date of receipt of your

application in VA unless you were incapacitated because

of a disability which prevented you from filing a claim for

a period of at least 30 days beginning with the date you

became permanently and totally disabled. If you want this

claim considered as a claim for retroactive payment, so

indicate in Item 42, “Remarks,” and identify the specific

disability which prevented you from filing.

VA pays disability pension based on the amount of income

that the veteran and family receive and the number of

dependents in the family. This is based on law. VA must

include as income all sources that federal law specifies.

You can find out what the current income limitations and

rates of benefits are by contacting your nearest VA office.

At least part of your active duty was during a

wartime period.

You are permanently and totally disabled (but not as

a result of your military service).

Your income is limited.

You should apply for pension benefits if all of the following

are true:

C. What is disability pension and how does VA decide

what I will or will not receive?

Use VA Form 21-527 to apply for disability pension if you

have previously filed a claim for compensation and/or

pension. If you have not filed a claim for compensation or

pension previously, you must use VA Form 21-526,

Veteran’s Application for Compensation and/or Pension.

B. What do I use VA Form 21-527 for?

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 1-800-827-1000 (Hearing

Impaired TDD line 1-800-829-4833). You may also

contact VA by Internet at

http://www.vba.va.gov/benefits/address.htm.

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

Note: Read very carefully, detach, and keep these instructions for your reference.

GENERAL INSTRUCTIONS

FOR INCOME-NET WORTH AND EMPLOYMENT STATEMENT

VA FORM 21-527
VA Form 21-22, Appointment of Veterans Service

Organization as Claimant’s Representative, or VA Form

22A, Appointment of Individual as Claimant’s

Representative. You may also download these forms

at http://www.va.gov/vaforms/. If you have already

designated a representative, no further action is required

on your part.

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

in processing or deciding my benefits?

You can ask for a personal hearing at any time during the

processing of your claim. That means you can ask for the

hearing while VA is processing your claim or after VA

has made a decision. You should contact the nearest VA

office and tell them that you want a personal hearing on

your case. Someone in the local VA office will arrange a

time and a place for your hearing. At this hearing, you can

bring witnesses. VA will record whatever you and your

witnesses say during the hearing and include it in the

official record. VA will furnish the hearing room and

officials, and prepare a transcript of the hearing. VA

cannot pay your expenses or the expenses of anyone you

want to bring with you to the hearing.

General Instructions Page 2

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 Compensation, Pension, Education, and Rehabilitation Records - VA, and published in

the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account

information is mandatory. Applicants are required to provide their SSN 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 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 U. S. C. 5701). Information that you furnish may be utilized in computer matching programs with other Federal or state

agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the

United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.

If you want to use a representative to help you with your

application, contact the nearest VA office. Depending on

the type of representative you want to designate, we will

send you one of the following forms:

A representative can be an accredited member of an

accredited organization or other service organization that

the Secretary of Veterans Affairs recognizes, an agent

recognized by VA, or a licensed lawyer. Agents and

attorneys can charge you for services that you get from

them only after the Board of Veterans’ Appeals (BVA)

gives you their final decision about your application. That

means you can use an attorney during any stage of your

application for benefits. However, the agent or attorney

cannot charge you for services unless you are trying to

resolve a dispute with VA after BVA has made a decision

about your claim.

H. How can I assign someone to act as my

representative?

When you have completed this application mail it or take

it to a VA regional office. Be sure to attach any materials

that support and explain your claim. Also, make a

photocopy of your application and everything that you

submit to VA before you mail it.

G. What do I do when I have completed my

application?

VA FORM 21-527, JUN 2004
INCOME-NET WORTH AND EMPLOYMENT STATEMENT

VA FORM 21-527

Please read the attached "General Instructions" before you fill out this form.

Evening

SECTION

I

1. What is your name?

4. What is your address?

City

3. What is your VA file number?

5. What are your telephone numbers?

 (Include Area Code)

Daytime

(DO NOT WRITE IN THIS SPACE)

6. What is your e-mail address?

OMB Approved No. 2900-0002

Respondent Burden: 1 hour

First Middle Last Suffix (If applicable)

Tell us

about

you

State ZIP Code Country 

Street address, Rural Route, or P.O. Box Apt. number

2. What is your Social Security number?

Tell us

about

your

marriage

SECTION

II

8. When were you married?

(If "Yes," answer Item 13b also)

7. What is your marital status?

mo day yr

9. Where did you get married? (city/state or country)

11. When is your spouse's birthday?

13a. Is your spouse also a veteran?

mo day yr

First Middle Last

12. What is your spouse's Social Security number?

13b. What is your spouse's VA file number (If any)?

NOTE: You

should

provide a

copy of your

marriage

certificate

10. What is your spouse's name?

(If you are divorced, widowed or never married, skip to Section III)

VA FORM

JUN 2004 21-527 EXISTING STOCKS OF VA FORM 21-527, Page 1 FEB 1999 WILL BE USED

14. Do you live with your spouse?

15. What is your spouse's address?

City

Street address, Rural Route, or P.O. Box Apt. number

State ZIP Code Country 

(If "No," answer Items 15 through 17 also. If "Yes," skip to Section III.)

16. Tell us why you are not living with your

 spouse. 

17. How much do you contribute monthly to your

 spouse's support?

Married Divorced Widowed Never Married

Yes No

Yes No

$
Tell us about

any previous

marriages

 Page 2

Your spouse's previous marriages

You must furnish complete information about all your and your present spouse's previous

marriages. If you need additional space, please attach a separate sheet of paper providing the

requested information about the marriages.

Your previous marriages

18b. Date of

 Marriage

mo day yr

mo day yr

18c. Place

(city/state or country)

18d. To whom

 married

(first, middle initial, last

 name)

18e. Date marriage

 ended

mo day yr

mo day yr

18f. Place

(city/state or country)

18g. How marriage

 ended

 (death, divorce)

19a. How many times has your current spouse been married?

19b. Date of

 Marriage

mo day yr

mo day yr

19c. Place 19d. To whom

 married

19e. Date marriage

 ended

mo day yr

mo day yr

19f. Place 19g. How marriage

 ended

SECTION

III

18a. How many times have you been married?

Tell us about

your

unmarried

children

VA recognizes your biological children, adopted children, and stepchildren as dependents.

These children must be unmarried and:

SECTION

IV

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.

If you need additional space, please attach a separate sheet of paper providing the

requested information about each child.

Note: You should provide a

copy of the public record of

birth for each child or a copy

of the court record of adoption

for each adopted child.

"Seriously disabled" (Item 21h) means that the child became permanently unable to

support himself/herself before reaching age 18. Furnish a statement from an attending

physician or other medical evidence which shows the nature and extent of the physical

or mental impairment.

20. Do you have any dependent children?

Yes No (If "No," skip to Section V)

(city/state or country) (first, middle initial,

last name)

(city/state or country) (death, divorce)

VA FORM 21-527, JUN 2004
SECTION IV Tell us about your unmarried children (continued)

 Page 3

21a. Name of child

(First, middle initial,

Last)

21b. Date and place

of birth (City/State

or Country)

Tell us about the children listed above who don't live with you.

22a. Name of child

 (first, middle initial, last)

22b. Child's Complete Address 22c. Name of person the child

 lives with (if applicable)

22d. Monthly amount

 you contribute to

 child's support

Tell us

about your

disability

and

background

SECTION

V

23a. What disability(ies) prevent you from working?

25c. What is the name and complete mailing

 address of the facility or doctor?

Ended

(If "No," answer

Item 26b also)

25a. Are you now, or have you recently been

 hospitalized or given outpatient or home-

 based care?

Began

25b. Tell us the dates of the recent

 hospitalization or care.

26c. Were you self-employed before becoming

 totally disabled?

24. Are you claiming a special monthly pension

 because you need the regular assistance of another

 person, are blind, nearly blind, or having severe

 visual problems, or are housebound?

(If "Yes," answer

Items 26d and 26e also)

26a. Are you now employed? 26b. When did you last work?

26d. What kind of work did you do?

(If "Yes," answer

Items 25b and 25c also)

26e. Are you still self-employed? 26f. What kind of work do you do now?

23b. When did the disability(ies) begin?

21c. Social Security

Number

$

$

$

mo day yr

mo day yr

mo day yr

mo day yr

21i. Child

previously

married

21h.

Seriously

disabled

21g. 18 -

23 yrs old

and in

school

21f.

Stepchild

21e.

Adopted

21d.

Biological

mo day yr

(If "Yes," answer Item

26f also)

mo day yr

mo day yr

Yes No Yes No

Yes No

Yes No

Yes No

VA FORM 21-527, JUN 2004
SECTION V Tell us about your disability and background (continued)

Page 4

27b. List the other training or experience you have and any certificates that you hold.

27a. Check the highest year of education you completed:

Grade school:

College:

Tell us

your work

history

SECTION

VI

28a. What was the name and

 address of your employer?

28d. When did

 your work

 end?

28b. What was

 your job

 title?

28c. When did

 your work

 begin?

28f. What were your

 total annual

 earnings?

28e. How many

 days were

 lost due to

 disability?

$

$

$

mo day yr mo day yr

mo day yr mo day yr

mo day yr mo day yr

In the table below, tell us about all of your employment, including selfemployment, for one year before you became disabled to the present.

Tell us if

you are

in a

nursing

home

SECTION

VII

29b. What is the name and complete mailing

 address of the facility?

(If "Yes," answer Item 29b also)

29c. Does Medicaid cover all or part of

 your nursing home costs?

(If "No," answer Item 29d also)

To get your claim

processed faster,

provide a statement

by an official of the

nursing home that

tells us that you are

a patient in the

nursing home

because of a

physical or mental

disability and tells

us the amount you

pay out-of-pocket

for your care.

29a. Are you now in a nursing home?

29d. Have you applied for Medicaid?

1 2 3 4 5 6 7 8 9 10 11 12

1 2 3 4 Over 4

Yes No

Yes No Yes No

VA FORM 21-527, JUN 2004
Tell us the

net worth

of you and

your

dependents

SECTION

VIII

 Page 5

VA cannot pay you pension if your net worth is sizeable. 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. You must report net worth for yourself and all persons for whom

you are claiming benefits.

Source Veteran

30a.

30b.

30c.

Spouse

Child(ren)

30f.

30e.

Name: Name: Name:

30d.

Cash, bank

accounts,

certificates of

deposit (CDs)

IRAs, Keogh

Plans, etc.

Stocks, bonds,

mutual funds

All other property

Real property (not

your home)

Value of business

assets

(first, middle initial, last) (first, middle initial, last) (first, middle initial, last)

Payments from any

source will be counted,

unless the law says

that they don't need to

be counted. Report all

income, and VA will

determine any amount

that does not count.

SECTION

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

Do not report the same information in both tables.

If you expect to receive a payment, but you don't know how much it will be, write "Unknown" in

the space.

If you do not receive any payments from one of the sources that we list, write "0" or "None" in the

space.

If you are receiving monthly benefits, give us a copy of your most recent award letter. This will

help us determine the amount of benefits you should be paid.

31. Have you claimed or are you receiving disability benefits from the Social Security Administration

 (SSA)?

Tell us

about the

income of

you and

your

dependents

For Items 30a through 30f, provide the amounts. If none, write "0" or "None."

 Yes No

VA FORM 21-527, JUN 2004
SECTION IX Tell us about the income of you and your dependents (continued)

Monthly Income - Tell us the income you and your dependents receive every month

Sources of

recurring monthly

income

Spouse

Name:

Veteran

Child(ren)

Name: Name:

32g.

32f.

32e.

32c.

32b.

32a.

Sources of income

for the next 12

months

Expected income for the next 12 months - Tell us about other income for you and your dependents

Veteran Spouse

Name: Name: Name:

Child(ren)

33a.

33b.

33c.

33d.

32d.

Black Lung

Benefits

U.S. Railroad

Retirement

U.S. Civil Service

Social Security

Military

Retirement

Other income

received monthly

(Please write

source below)

Supplemental

Security Income

(SSI)/Public

Assistance

Gross wages and

salary

Total interest and

dividends

Worker's

compensation or

unemployment

compensation

Other income

expected

(Please write

source below)

(first, middle initial, last) (first, middle initial, last)

(first, middle initial, last) (first, middle initial, last) (first, middle initial, last)

(first, middle initial, last)

VA FORM 21-527, JUN 2004 Page 6
SECTION X

34a. Amount paid by

you

34e. Disability or

relationship of person for

whom expenses paid

Tell us about

medical, legal or

other

unreimbursed

expenses

34b. Date Paid 34c. Purpose

(Doctor's fees, hospital

charges, attorney fees,

etc.)

34d. Paid to

(Name of doctor, hospital,

pharmacy, etc.)

Family medical expenses and certain other expenses actually paid by you may be deductible from your income.

Show the amount of unreimbursed medical expenses, including the Medicare deduction, you paid for yourself or

relatives who are members of your household. Also, show unreimbursed last illness and burial expenses and

educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are unreimbursed

amounts paid by you for the last illness and burial of a spouse or child at any time prior to the end of the year

following the year of death. Educational or vocational rehabilitation expenses are amounts paid for courses of

education, including tuition, fees, and materials. Show medical, legal or other expenses you paid because of a

disability for which civilian disability benefits have been awarded. When determining your income, we may be

able to deduct them from the disability benefits for the year in which the expenses are paid. Do not include any

expenses for which you were reimbursed. If more space is needed attach a separate sheet.

All Federal payments beginning January 2, 1999, must be made by electronic funds transfer (EFT) also called

Direct Deposit. Please attach a voided personal check or deposit slip or provide the information requested below in

Items 35, 36 and 37 to enroll in Direct Deposit. If you do not have a bank account we will give you a waiver from

Direct Deposit, just check the box below in Item 35. The Treasury Department is working on making bank

accounts available to you. Once these accounts are available, you will be able to decide whether you wish to signup for one of the accounts or continue to receive a paper check. You can also request a waiver if you have other

circumstances that you feel would cause you a hardship to be enrolled in Direct Deposit. You can write to:

Department of Veterans Affairs, 125 S. Main Street Suite B, Muskogee OK 74401-7004, and give us a brief

description of why you do not wish to participate in Direct Deposit.

If benefits are

awarded we will need more

information in order to

process any payments to

you. Please read the

paragraph starting

with, "All Federal

payments..." and then

either:

36. Name of financial institution

37. Routing or transit number

Account number

35. Account number (Please check the appropriate box and provide that account number, if applicable)

 Page 7

1.

I certify that I do not have an account with a financial

institution or certified payment agent Savings

Checking

SECTION

XI

Give us direct

deposit information

mo day yr

mo day yr

mo day yr

mo day yr

$

Attach a voided

check, or

2. Answer Items

35-37 to the right.

$

$

$

VA FORM 21-527, JUN 2004
Give us

your

signature

Remarks - Use this

space for any

additional

statements

that you would like

to make concerning

your application.

I certify and authorize the release of information:

I certify that the statements in this document are true and complete to the best of my knowledge. I

authorize any person or entity, including but not limited to any organization, service provider,

employer, or government agency, to give the Department of Veterans Affairs any information about

me except protected health information, and I waive any privilege which makes the information

confidential.

38. Your signature

40b. Printed name and address of witness

39. Today's date

40a.

41a. 41b. Printed name and address of witness

1.

 

 

IMPORTANT

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 to be false, or

for the fraudulent

acceptance of any payment

which you are not entitled

to.

42.

 Page 8

SECTION

XIII

SECTION

XII

Read the box that starts,

"I certify and authorize

the release of

information:"

2. Sign the box that

says, "Your signature."

3. If you sign with an "X,"

then you must have 2

people you know

witness you as you sign.

They must then sign the

form and print their

names and addresses

also.

Remarks (If you need more space to answer a question or have a comment about a specific item

number on this form please identify your answer or statement by the part and item number)

mo day yr

Signature of witness (If claimant

signed above using an "X")

Signature of witness (If claimant

signed above using an "X")

VA FORM 21-527, JUN 2004