21P-4165

Pension Claim Questionnaire for Farm Income

Agency
VA
Revision
December 2025
Fillable fields
106
Pages
3
Official source
VA form page
Checked
October 20, 2026
Fill 21P-4165 online
Page 1 of form 21P-4165

VA Form 21P-4165: Pension Claim Questionnaire for Farm Income

VA Form 21P-4165 is the U.S. Department of Veterans Affairs Pension Claim Questionnaire for Farm Income. The form opens by saying that before further action can be taken on the claim, VA needs more information about the claimant's farming activity, and it asks that every question be answered accurately and completely. VA's form page lists it under pension and family member and caregiver benefits.

The form is three pages. It asks for gross farm receipts for last year, this year and next year, farm operating expenses, the acreage owned, crops, pasture and livestock, and whether the farm is rented to or from someone else. Page 3 holds the Privacy Act and respondent burden notices.

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-4165: Pension Claim Questionnaire for Farm Income, as printed by VA

What's on VA Form 21P-4165

Items 1 and 2: reporting period

A period starting and ending date. The form says THIS YEAR means the current calendar year unless otherwise indicated in these items, LAST YEAR the year before it and NEXT YEAR the year after it.

Section I: Veteran and claimant information

Items 3 to 11 cover the Veteran's name, Social Security number and file number, then the claimant's name, Social Security number, date of birth, mailing address, telephone number and email address.

Section II: gross receipts

The total of all gross receipts, including crops, livestock, produce, farm rentals, soil bank or ASCA payments, cash and rents, for last year, this year and next year in Items 12 to 14, then the owners in Item 15.

Section III: farm operating expenses

Item 16 lists hired labor, feeds, supplies, machine hire, repairs and maintenance, cash rent, property taxes, property insurance and interest, each for last year and this year, with totals in Item 17.

Items 18 to 21: land, crops and livestock

Total acreage owned, whether the primary residence is on it and the value of that part, acreage in crops and pasture, livestock on the farm now, and whether the farm is rented to or from someone else.

Remarks, signature and witnesses

Item 22 remarks continue on page 3. Section IV is the claimant's certification, signature in ink and date, and Section V holds two witness lines for a signature by mark.

How to fill out VA Form 21P-4165

  1. 1

    Read the instructions and set the period

    The form asks that all questions be answered accurately and completely and points to the Privacy Act and burden information on page 3. Items 1 and 2 set the period the year references follow.

  2. 2

    Fill in Section I

    Enter the Veteran's details, and the claimant's details if the claimant is not the Veteran.

  3. 3

    Report receipts and expenses

    The form asks for totals to include cents. For expenses it says to include the landlord's share where the landlord shares expenses, that payments on mortgage principal are not deductible, and not to include depreciation.

  4. 4

    Answer the land and livestock questions

    Complete Items 18C and 18D if the primary residence is on the owned acreage. If the farm is rented, Item 21 asks for a copy of the rental agreement or lease, or a detailed statement of the agreement.

  5. 5

    Use Remarks for extra space

    The form says to use the remarks section when more space is needed for any question.

  6. 6

    Sign and date it

    Sign Item 23A in ink and enter the date in Item 23B. A signature by X mark needs the two witnesses in Section V.

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Sending it and edition details

Mailing address

This edition of the form does not print a mailing address, and VA's form page offers the PDF download only. Page 3 gives an email address for comments on the burden estimate and says not to send the completed form there.

Rental papers

If the answer to Item 21 is yes, the form asks for a copy of the farm rental agreement or lease, or a statement setting out the particulars of the agreement in detail.

Privacy Act

The notice says a response is required to obtain or retain benefits and that the Social Security number is requested under 38 U.S.C. 5101(c)(1).

Edition

The DEC 2025 edition supersedes VA Form 21-4165, AUG 2022. It carries OMB Control No. 2900-0095, which expires 12/31/2028, with a respondent burden of 30 minutes.

Related forms

Who uses VA Form 21P-4165?

  • Claimants asked about farming activity

    The instructions say VA needs more information about the claimant's farming activity before further action can be taken on the claim. VA's page lists the form under pension benefits.

  • Veterans

    Section I starts with the Veteran's name, Social Security number and VA file number.

  • Claimants who are not the Veteran

    Items 6 to 11 ask for the claimant's name if the claimant is not the Veteran, with Social Security number, date of birth, mailing address, phone and email.

  • Owners of the farm business

    Item 15 lists the names of the owners of the business and the degree of ownership of each, as shown by deed, trust or other document.

  • Witnesses to a signature by mark

    If the claimant signs with an X, the form says two people who personally know the person making the statement witness it and give their signatures and addresses.

The form names these people in its sections.

Official sources and the blank

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Questions about Form 21P-4165

What is VA Form 21P-4165 used for?

The form says VA needs more information about the claimant's farming activity before further action can be taken on the claim. It asks about farm receipts, expenses, acreage, crops and livestock.

What do THIS YEAR, LAST YEAR and NEXT YEAR mean on the form?

The form says THIS YEAR is the current calendar year unless otherwise indicated in Items 1 and 2, LAST YEAR is the year before THIS YEAR, and NEXT YEAR is the year after it.

Which costs does the form leave out of farm expenses?

Section III says payments on the principal of a mortgage are not deductible and not to include depreciation. Repairs and maintenance cover farm buildings and machinery except dwellings.

Does the form ask for a farm lease?

If the farm is rented to or from someone else, Item 21 asks for a copy of the rental agreement or lease, or a detailed statement of the agreement.

Where do I send VA Form 21P-4165?

This edition does not print a mailing address. The email address on page 3 is for comments on the burden estimate only, and the form says not to send the completed form there.

Can the claimant sign with an X?

Yes. Section V says a signature by mark is witnessed by two people who personally know the person making the statement, with their signatures and addresses.