21P-0571

Application for Exclusion of Children’s Income

Agency
VA
Revision
May 2024
Fillable fields
74
Pages
2
Official source
VA form page
Checked
October 20, 2026
Fill 21P-0571 online
Page 1 of form 21P-0571

VA Form 21P-0571: Application for Exclusion of Children's Income

VA Form 21P-0571 is the U.S. Department of Veterans Affairs Application for Exclusion of Children's Income. The form says VA can exclude all or some of your children's income in computing your rate of pension if counting the children's income would cause hardship or if this income is unavailable to you, and asks that the form be fully completed to claim the exclusion.

The form is two pages. Page 1 identifies the Veteran and the claimant and has columns for up to four children, with questions about whether each child's income is reasonably available. Page 2 reports average monthly household expenses, expected changes, remarks and the claimant's signature.

VA's page lists the form under Family member and caregiver benefits and Pension, with a downloadable PDF and no online version. You can fill out the PDF free in your browser on this page and download the result without an account.

Top of page 1 of VA Form 21P-0571: Application for Exclusion of Children's Income, as printed by VA

What's on VA Form 21P-0571

Items 1 to 5: identification

The Veteran's name, VA file number, the claimant's name if other than the Veteran, the Veteran's Social Security number and the claimant's address.

Items 6 to 8: each child

In up to four columns: the child's name, date of birth, Social Security number and whether all of the child's income is reasonably available to you.

Items 9 to 13: unavailable income

The specific income not available to you, the payee's name, whether the payee lives in your household all year, how many months they did in the 12 months before signing, and any other reasons.

Item 14: monthly household expenses

Average monthly expenses for the 12 months before you sign: rent or mortgage, food, utilities and heat, telephone, automobile, public transportation, clothing, taxes, insurance, furniture, interest and other living expenses.

Items 15 to 17: changes and remarks

Whether household expenses will change significantly in the next 12 months, whether any household member's income changed since last reported to VA, and a remarks space.

Item 18: certification and signature

A certification that the statements are true and correct, the claimant's signature in ink and the date, followed by the penalty, fees for claims and Privacy Act notices.

How to complete VA Form 21P-0571

  1. 1

    Identify the Veteran and claimant

    Fill in Items 1 to 5. Item 3 is only for a claimant other than the Veteran.

  2. 2

    Answer Item 8 for each child

    The form says a No answer means completing Items 9 thru 13 for that child, and a Yes answer skips to Item 14.

  3. 3

    List household expenses

    Report average monthly expenses in Item 14 for the 12 months before you sign, without medical expenses.

  4. 4

    Explain changes in Item 17

    The form asks for a full explanation in Item 17 for a Yes in Item 15 or 16, and a continuation sheet if more space is needed.

  5. 5

    Sign and date it

    Sign Item 18A in ink and enter the date in Item 18B.

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Sending it and edition details

Where to send it

The PDF does not print a mailing address, and VA's form page lists a downloadable PDF with no online version.

Medical expenses

The form says to report medical expenses on the Eligibility Verification Report (EVR), not on this form.

Edition

The MAY 2024 edition carries OMB Control No. 2900-0510, which expires 05/31/2027, with a respondent burden of 45 minutes.

Related forms

Who uses VA Form 21P-0571?

  • Pension claimants with children

    The form is for a claimant asking VA to exclude all or some of the children's income when VA computes the rate of pension.

  • Veterans or other claimants

    Item 1 names the Veteran, and Item 3 is for the name of the claimant if other than the Veteran.

  • Households where a child's income is unavailable

    Items 9 to 13 describe income that is not available to you, for example Social Security or wages, and whose name appears on the check.

  • Households reporting hardship

    The form says the exclusion can apply if counting the children's income would cause hardship. Item 14 reports the household's average monthly expenses.

  • Medical expenses go elsewhere

    The form says not to report medical expenses on this form but on the Eligibility Verification Report (EVR), which VA mails annually.

The form describes who completes it and which items apply.

Official sources and the blank

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Questions about Form 21P-0571

What is VA Form 21P-0571 used for?

The form says VA can exclude all or some of your children's income in computing your rate of pension if counting it would cause hardship or if the income is unavailable to you. The form is used to claim that exclusion.

How many children fit on the form?

Page 1 has four child columns for Items 6 to 13.

Which period do the household expenses cover?

The form says the figures should reflect your expenses for the 12 months preceding the date you sign the form.

Do I list medical expenses on VA Form 21P-0571?

No. The form says not to report medical expenses on it and to report them on your Eligibility Verification Report (EVR), which VA mails annually.

Can I submit VA Form 21P-0571 online?

VA's form page lists a downloadable PDF and does not list an online version.