VA 21-0788 Form Fillable Template

Reginfo. gov/public/do/PRAMain. If desired you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. VA FORM 21-0788 JUN 2014. 2D. STOCKS BONDS MUTUAL FUNDS ETC. 2E. REAL PROPERTY Not your home 2F. ALL OTHER PROPERTY AND ASSETS VA FORM JUN 2014 21-0788 SUPERSEDES VA FORM 21-0788 MAY 2009 WHICH WILL NOT BE USED. RESPONDENT BURDEN - We need this information to determine whether an apportionment of VA disability or death benefits may be made 38 U.S.C. 5307. 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. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www. OMB Approved No* 2900-0666 Respondent Burden 30 minutes Expiration Date 9/30/2014 DO NOT WRITE IN THIS SPACE VA DATE STAMP INFORMATION REGARDING APPORTIONMENT OF BENEFICIARY S AWARD INSTRUCTIONS All or part of a veteran s disability award may be apportioned paid to the veteran s spouse child or dependent parent. A surviving spouse s award may also be apportioned for the veteran s child or children* Print all answers clearly. If an answer is none or 0 write that or line through the space provided* 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 form* IMPORTANT If you are certifying that you are married for the purpose of VA benefits your marriage must be recognized by the place where you and/or your spouse resided at the time of marriage or where you and/or your spouse resided when you filed your claim or a later date when you became eligible for benefits 38 U*S*C. 103 c. Additional guidance on when VA recognizes marriages is available at http //www. va*gov/opa/marriage/. 1. FIRST MIDDLE LAST NAME OF VETERAN 2. VA FILE NUMBER C/CSS- 3B. MAILING ADDRESS Number and street or rural route city or P. O. State and ZIP Code 3D. E-MAIL ADDRESS If applicable 3C. TELEPHONE NUMBER Include Area Code Daytime Evening 4A. WHO ARE YOU REQUESTING AN APPORTIONMENT FOR List first middle and last names 4B. WHAT IS HIS/HER RELATIONSHIP TO THE VETERAN 5A. HOW MUCH IS THE VETERAN OR VETERAN S SURVIVING SPOUSE CONTRIBUTING TO THE PERSON S FOR WHOM AN APPORTIONMENT IS BEING CLAIMED 5B. HOW OFTEN ARE THE CONTRIBUTIONS MADE 6. IF THE SPOUSE IS CLAIMING AN APPORTIONMENT IS HE/SHE LIVING WITH ANOTHER PERSON AND HOLDING HIMSELF/HERSELF OUT OPENLY TO THE PUBLIC AS THE SPOUSE OF THE OTHER PERSON YES NO If Yes provide an explanation 7. HAS THE VETERAN S CHILD REN BEEN LEGALLY ADOPTED BY ANOTHER PERSON PART I - INCOME AND NET WORTH Report all income and net worth. Report the gross amounts before you take out deductions for taxes insurance etc* If you do not receive income or net worth from a particular source write 0 or none in the space provided* Do not leave the space blank.