Application for Exclusion of Children's Income from Computation of Pension
A child who is a dependent on your pension claim has their own income (part-time job, SSA survivors benefits, trust distributions) that is currently raising your household countable income and reducing your pension.
Gather before you start
Attach with the form
Section I - Pension Recipient Identification
Blocks 1-3Pension recipient name, SSN, VA File NumberPII
Your information as the pension recipient (veteran or surviving spouse). Include VA File Number from your pension award letter so this request attaches to the correct file.
(legal name, SSN, VA pension file number)
- Omitting VA File Number - exclusion request cannot be matched to the pension file.
Section II - Child's Income Information
Blocks 4-12Child name, SSN, income type, amount, and supporting documentationRepeatable
For each child whose income you want excluded: their full legal name, Social Security number, and complete description of all income including type (wages, SSA survivors, trust, other), monthly and annual amount, and who pays it (employer name, SSA, trustee). Attach documentation proving it is the child's income, not a household income.
e.g., Emily Smith, SSN: 234-56-7890; Part-time wages from Pizza Palace $450/mo = $5,400/yr; SSA survivors benefit $320/mo = $3,840/yr
- Not documenting the source - VA needs to verify it is the child's income, not yours.
- Forgetting to apply annually - if the child continues earning, the exclusion should be maintained in each annual EVR.
Section III - Certification
Blocks 13-14Pension recipient signature and datePII
Sign and date certifying the income amounts are accurate and belong to the dependent child(ren).
(signature/date)
- Not requesting retroactive adjustment - if the child has had income for months before you file, ask VA to recalculate from the date the income began.