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This form should be used to report or verify income and/or net worth. Changes to income and net worth over multiple years must be reported on a separate VA Form 21P-0969 for each year.
Income Verification is a process VA uses to match Veterans’ gross household income information obtained from the Internal Revenue Service (IRS) and Social Security Administration (SSA). Gross household income includes income of the Veteran, spouse and dependent children.
VERIFICATION OF EMPLOYMENT/LOSS OF INCOME. Date:________________________ ___________________________________________ In order to determine the eligibility of ___________________________________________ for public assistance, please assist us by answering the questions below and returning this form to us by __________________________ .
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.
: VA will compare the information you report on this form to Internal Revenue Service (IRS) and Social Security Administration (SSA) records to verify your income for the past three tax years for which information is available.
Veteran - Income Verification Response. Income Year: Case Number: Before completing this form, please refer to the enclosed instructions which include examples of deductible out-of-pocket non-reimbursed expenses.
It is VHA policy to verify Veterans’ self-reported income (including spouse or partner and dependents, if applicable) for NSC Veterans and non-compensable zero % SC Veterans who have no other special eligibility for receiving VA health care benefits.
