Item 1: identification
The claimant's name and Social Security number and the Veteran's or wage earner's Social Security number.
21P-8941
REPS Annual Eligibility Report (Under the Provisions of Section 256, Public Law 97-377)
- Agency
- VA
- Revision
- April 2024
- Fillable fields
- 29
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 21P-8941: REPS Annual Eligibility Report
VA Form 21P-8941 is the U.S. Department of Veterans Affairs REPS Annual Eligibility Report, issued under Public Law 97-377. REPS is VA's Restored Entitlement Program for Survivors. The report asks a claimant for last year's and this year's earnings, employment history, marital status and the status of the youngest dependent child in their care while age 16 to 18.
The form is two pages. Page 1 holds the Privacy Act and respondent burden notices, Items 1 to 8 and the certification and signature. Page 2 has the instructions for the earnings items and a list of income the form says generally does not have to be reported. The instructions refer to an annual earnings limit shown in the letter attached to this form. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 21P-8941
Items 2 to 4: earnings
Gross earnings last year, anticipated gross earnings this year, and whether you were or are self-employed, with the number of hours worked per week.
Item 5: employment history
Whether you began or quit working last year and the dates, whether you are currently employed, the name and address of your employers, and whether you anticipate beginning employment this year.
Item 6: marital status
Whether you remarried last year or this year to date, the date of marriage and your complete married name.
Item 7: youngest dependent child
The name of the child of the Veteran in your care between ages 16 and 18, and if the child married or left your care, the dates and an explanation.
Items 8 and 9: remarks and signature
Space for remarks, then the certification, the signature of the claimant or guardian in ink, the date, and daytime and evening phone numbers.
How to fill out VA Form 21P-8941
- 1
Check the limit in VA's letter
The instructions say all benefits due for the year are received if total annual earnings do not exceed the limit shown in the attached letter, and that $1 will be deducted from benefits for each $2 earned over that limit.
- 2
Enter last year's gross earnings
Item 2A takes total gross wages for January through December of last year. The instructions say these are generally the same as the highest dollar amount on your W-2 forms, with net earnings from self-employment added.
- 3
Estimate this year's earnings
Item 2B takes the highest amount you estimate earning this year, NONE if you expect no earnings, or UNKNOWN if you cannot estimate. The form says not to leave the box blank.
- 4
Answer the employment, marriage and child items
Complete Items 3 to 7, following each If Yes note, and use Item 8 to explain a fiscal year, a sale or transfer of a business, or foreign earnings.
- 5
Sign and date it
The claimant or guardian signs Item 9A in ink, dates Item 9B and gives daytime and evening phone numbers in Item 9C.
Why fill Form 21P-8941 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
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- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Sending it and other details
Mailing address
Neither the form nor VA's form page prints a mailing address. The instructions refer to a letter attached to this form.
Online
VA's form page offers the form as a downloadable PDF and lists no online version.
Income not reported
Page 2 lists income that generally does not have to be reported, such as Social Security, veterans' and public assistance benefits, pension payments, interest from savings accounts, gifts or inheritances, unemployment compensation and jury duty payment.
Edition
The April 2024 edition supersedes the March 2018 edition, which the form says will not be used. It carries OMB Control No. 2900-0405, which expires 04/30/2027.
Related forms
21P-8924
Application of Surviving Spouse or Child for REPS Benefits (Restored Entitlement Program for Survivors)
61 fields, 3 pages
21P-0537
Marital Status Questionnaire
37 fields, 3 pages
21P-534EZ
Application for D.I.C., Survivors Pension, and/or Accrued Benefits
626 fields, 20 pages
21-4138
Statement in Support of Claim (VA Form 21-4138)
33 fields, 2 pages
Who uses VA Form 21P-8941?
The form describes who reports and who signs.
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Questions about Form 21P-8941
What is VA Form 21P-8941 for?
It is the REPS Annual Eligibility Report. It asks for earnings, employment history, marital status and the status of the youngest dependent child in your care while age 16 to 18.
What if I leave Item 2B blank?
The form says not to leave it blank: write NONE if no earnings are expected or UNKNOWN if you cannot estimate. It says that if Item 2B is not completed, no benefit can be paid for the current year until a report of earnings is filed.
Which income does not have to be reported?
The instructions list examples such as Social Security, railroad retirement, civil service, veterans' and public assistance benefits, pension payments, investment income unless you are a dealer in securities, gifts or inheritances, and unemployment compensation.
How do earnings affect REPS benefits?
The instructions say all benefits due for the year are received if total annual earnings do not exceed the limit in the attached letter, and that $1 will be deducted from benefits for each $2 earned over that limit.
Where do I report foreign earnings?
In Item 8. The form asks for the number of hours worked per month for each month employed if you had foreign earnings that were not subject to U.S. Social Security (FICA) taxes.
Who signs the report?
The claimant or guardian signs Item 9A in ink, certifying that the statements are true and correct to the best of their knowledge and belief.