21P-0969

Income and Asset Statement for Pension or Parents’ Dependency and Indemnity Compensation (D.I.C.) Claims

Agency
VA
Revision
November 2023
Fillable fields
428
Pages
11
Official source
VA form page
Checked
October 20, 2026
Fill 21P-0969 online
Page 1 of form 21P-0969

VA Form 21P-0969: Income and Asset Statement for Pension or Parents' DIC Claims

VA Form 21P-0969 is the U.S. Department of Veterans Affairs Income and Asset Statement for Pension or Parents' Dependency and Indemnity Compensation (D.I.C.) Claims. VA's form page says to use it if VA asks you to while completing VA Forms 21P-527EZ or 21P-534EZ, and that it can also be submitted to verify or update income or net worth. For changes over multiple years, the page says to submit a separate VA Form 21P-0969 each year.

The PDF is 11 pages: three pages of information, instructions and notices, then the statement in 14 sections. They run from identification and recurring income through financial accounts, owned assets, royalties, asset transfers, trusts, annuities, unreported assets, discontinued income and waived income, to the certification and witness signatures.

VA's page says the form can also be submitted online. 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-0969: Income and Asset Statement for Pension or Parents' DIC Claims, as printed by VA

What's on VA Form 21P-0969

Sections I and II: identification

The Veteran's name, Social Security number and file number, the claimant's name, Social Security number and phone, the type of claimant, and the period in Item 2E that the form covers.

Section III: recurring income

Income not tied to an account or asset, such as Social Security, retirement or pension, wages, unemployment or civil service, with the recipient, gross monthly income and payer.

Sections IV to VI: accounts, assets, royalties

Income and net worth from financial accounts, from owned assets such as rental property, farm or business earnings, and from royalties and other properties.

Sections VII to IX: transfers, trusts, annuities

Assets sold, conveyed, traded or given away in the current year and/or prior 3 tax years, then trusts and annuities with their values, added funds and income.

Sections X to XII: other assets and income

Assets not already reported, income that has stopped or was irregular, and income waived or expected to be waived in the next 12 months.

Sections XIII and XIV: signature and witnesses

The certification, signature and date, then two witness signatures, names and addresses if the claimant signed with an "X".

How to file VA Form 21P-0969

  1. 1

    Read the information pages

    The first pages define assets, list whose income and assets to report, and explain each section with examples.

  2. 2

    Set the reporting period

    In Item 2E, the form says to report current information for an initial application, the date range in VA's letter when responding to VA, or changes from the date they took effect.

  3. 3

    Answer each section's opening question

    Each section starts with a Yes or No question, and a No answer skips to the next section. The form asks for an answer in each of its 14 sections.

  4. 4

    Attach the documents the form lists

    The instructions name VA Form 21P-4165 for farm income and VA Form 21P-4185 for business or rental income, a fair market value statement for property, and trust or annuity contracts and statements.

  5. 5

    Sign and date it

    Sign Item 13A and date Item 13B. If you sign with an "X", the form asks for two witness signatures in Section XIV.

  6. 6

    Mail it or submit online

    Mail it to the Pension Intake Center in Janesville, Wisconsin, or submit it online through VA's form page.

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Where to send it

By mail

Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.

Online

VA's form page says you can submit this form online instead of filling out and sending the paper form.

Dependents and medical expenses

The form says to submit VA Form 21-686c to update dependents and VA Form 21P-8416, Medical Expense Report, to update medical expenses.

Income records

The form says VA will compare the information you report to IRS and SSA records to verify your income for the past three tax years for which information is available.

Edition

The NOV 2023 edition supersedes the DEC 2021 edition. It carries OMB Control No. 2900-0829, which expires 11/30/2026, with a respondent burden of 30 minutes.

Related forms

Who uses VA Form 21P-0969?

  • Claimants VA asks for it

    VA's page says to use it if VA asks you to while completing VA Form 21P-527EZ or VA Form 21P-534EZ.

  • Beneficiaries updating income or net worth

    VA's page says the form can also be submitted to verify or update income or net worth, with a separate form for each year of changes.

  • Veterans and surviving spouses

    The form lists whose income and assets each claimant type reports. For a Veteran, that is the Veteran, a spouse and children, with stated exceptions. For a surviving spouse, the spouse and children.

  • Surviving children and custodians

    For a surviving child or custodian, the form lists the child, the child's custodian unless the custodian is an institution, and the custodian's spouse.

  • Parents claiming DIC

    For a parent, the form lists income for the parent and the parent's spouse. It says parents' D.I.C. claimants do not need to report or provide documentation of their assets.

VA's form page and the form's Information for Claimants describe who files it and whose income it covers.

Official sources and the blank

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Questions about Form 21P-0969

When is VA Form 21P-0969 used?

VA's form page says to use it if VA asks you to while completing VA Forms 21P-527EZ or 21P-534EZ, or when you need to verify or update your income or net worth.

Do I need a separate form for each year?

VA's page and the form say changes over multiple years are reported on a separate VA Form 21P-0969 for each year.

Do parents claiming DIC report assets?

The form says parents' D.I.C. claimants do not need to report or provide documentation of their assets. Parents report income for themselves and their spouse.

Does my home count as an asset on this form?

The form's definition of assets excludes the value of your or your dependents' primary residence, including the residential lot area, not to exceed 2 acres.

What if I have more than one trust or annuity?

The form says to submit the information on a separate VA Form 21P-0969 or on VA Form 21-4138, Statement in Support of Claim, for each additional one.

Can I submit VA Form 21P-0969 online?

Yes. VA's form page says you can submit this form online instead of filling out and sending the paper form.

Where do I mail VA Form 21P-0969?

The form lists Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.