VA Form 21P-0969
Income and Asset Statement in Support of Claim for Pension or Parents' DIC
You have multiple income sources, multiple assets, or complex financial arrangements that cannot fit in the basic fields of 21P-527EZ or 21P-534EZ.
- Who fills it
- veteran
- Journey phase
- Evidence & Statements
- Estimated time
- 30-60 minutes with financial records gathered.
- When to file
- With the primary pension or DIC claim as an attachment when needed.
Official VA form page: https://www.va.gov/find-forms/about-form-21p-0969/
Gather before you start
- ▸Bank statements (checking, savings, CDs, money market) - most recent
- ▸Investment account statements (brokerage, IRA, 401k) - current balances
- ▸SSA award letter or benefit verification
- ▸Pension, annuity, trust, or rental income documentation
- ▸Property appraisals or tax assessments for real estate (excluding primary home)
- ▸Business ownership documentation if self-employed
Attach with the form
- ▸Filed as attachment to 21P-527EZ, 21P-534EZ, or 21P-535
- ▸Financial account statements supporting reported amounts
Section I - Claimant Identification
Blocks 1-3Claimant name, SSN, VA File NumberPII
Match your primary pension or DIC claim filing. This form must attach to the correct VA file.
(match primary claim filing)
Common mistakes
- ×Using the veteran's information when a surviving spouse is the claimant - use the claimant's information.
Section II - All Income Sources
Blocks 4-20Complete income schedule for all household members included in claimRepeatable
List every income source separately with monthly and annual amounts. Required for: claimant, spouse (if on claim), dependent children (their income counts too). Categories: wages/salary, Social Security (retirement, disability, survivors), pensions (civil service, military, private), interest and dividends, rental income, trust distributions, annuity payments, royalties, in-kind support (room/board provided by others).
e.g., SSA retirement: $1,200/mo ($14,400/yr) TSP/military retirement: $800/mo ($9,600/yr) Bank interest: $30/mo ($360/yr)
Common mistakes
- ×Not listing each source separately - VA needs individual line items, not totals.
- ×Forgetting that children's income (wages, SSA survivor benefits) is included when they are on the claim.
- ×Including VA benefits as income - they are excluded from countable income.
Authority
- 38 CFR 3.3 - Eligibility criteria for veterans pension: wartime service, discharge character, income below MAPR, and net worth below threshold.
- M21-1 V.iv.3 - Calculating IVAP for pension eligibility.
Section III - All Assets
Blocks 21-35Complete asset schedule for all household membersRepeatable
List all assets with current market value. Include: bank accounts (all types), certificates of deposit, brokerage accounts, mutual funds, stocks and bonds, IRAs (current market value), 401(k)s and other retirement accounts (current market value), real estate other than primary home (current appraised value minus mortgage balance = equity), business ownership value, life insurance cash value (if accessible), prepaid burial contracts exceeding the exemption limit. EXCLUDE: primary residence, one vehicle per household, household goods, personal effects.
e.g., Wells Fargo checking: $4,200 Chase savings: $18,500 Fidelity IRA: $67,000 (current market value) Vanguard brokerage: $23,000
Common mistakes
- ×Using the original contribution amount for IRAs instead of current market value - VA uses current value.
- ×Forgetting a CD or savings account at a bank you use infrequently.
- ×Reporting a second home at purchase price instead of current appraised value minus mortgage balance.
Authority
- 38 CFR 3.3 - Eligibility criteria for veterans pension: wartime service, discharge character, income below MAPR, and net worth below threshold.
Section IV - Certification
Blocks 36-37Claimant signature and datePII
Sign and date under penalty of perjury. VA compares reported assets and income to IRS, SSA, and financial institution records. Underreporting is federal fraud.
(signature/date)
Common mistakes
- ×Rounding figures - report exact balances from account statements.
- ×Not updating when accounts change significantly - if you file and then receive a large inheritance, you must report it.
Statutory and regulatory authority
- 38 CFR 3.3 - Eligibility criteria for veterans pension: wartime service, discharge character, income below MAPR, and net worth below threshold.
- M21-1 V.iv.3 - Calculating IVAP for pension eligibility.