Form 21P-4165 Pension Claim Questionnaire for Farm Income

OMB Approved No. 2900-0095
Respondent Burden: 30 minutes
Expiration Date: XX/XX/20XX

VA DATE STAMP

PENSION CLAIM QUESTIONNAIRE
FOR FARM INCOME

(DO NOT WRITE IN THIS SPACE)

INSTRUCTIONS: Before further action can be taken on your claim, we must have more information
concerning your farming activity. Please answer all questions on this form accurately and completely. Please
read the Privacy Act and Respondent Burden Information on Page 3 before completing form.
1. PERIOD STARTING DATE (MM/DD/YYYY)

References in this form to "THIS YEAR" refer to the
period. (If blank, "THIS YEAR" refers to the current
calendar year. References to "LAST YEAR" refer to
the 12 month period preceding "THIS YEAR".)

Month

Day

2. PERIOD ENDING DATE (MM/DD/YYYY)

Year

Month

Day

Year

SECTION I: VETERAN AND CLAIMANT INFORMATION
3. VETERAN'S NAME (First, Middle Initial, Last)

4. VETERAN'S SOCIAL SECURITY NUMBER

5. VETERAN'S FILE NUMBER

6. CLAIMANT'S NAME (If claimant is not the veteran - First, Middle Initial, Last)

8. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY)

7. CLAIMANT'S SOCIAL SECURITY NUMBER

Month

Day

Year

9. CLAIMAINT'S CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)
No. &
Street
Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

10. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)

11. CLAIMANT E-MAIL ADDRESS

SECTION II: REPORT OF THE TOTAL OF ALL GROSS RECEIPTS

(Including crops, breeding livestock, other livestock, produce, farm rentals, soil bank or ASCA payments, patronage division, cash, rents, etc.)
12. AMOUNT RECEIVED LAST YEAR
$

13. AMOUNT EXPECTED THIS YEAR
$

14. AMOUNT ANTICIPATED NEXT YEAR
$

15. NAME(S) OF OWNER(S) OF BUSINESS AND DEGREE OF OWNERSHIP OF EACH (As shown by deed, trust or other document)
A. NAME OF OWNER OF BUSINESS

VA FORM
XXX 20XX

21P-4165

SUPERSEDES VA FORM 21-4165, AUG 2022.

B. DEGREE OF OWNERSHIP

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SECTION III: FARM OPERATING EXPENSES

(Include landlord's share for all items in which he/she shares expenses. Payments on principal of mortgage are not deductible. Do not include depreciation)
16. FARM OPERATING EXPENSE
A. HIRED LABOR

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

B. FEEDS PURCHASED

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

C. SUPPLIES PURCHASED

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

D. MACHINE HIRE

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

E. REPAIRS AND MAINTENANCE OF FARM
BUILDINGS AND MACHINERY (Except dwellings)

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

F. CASH RENT

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

G. PROPERTY TAXES

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

H. INSURANCE ON PROPERTY

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

AMOUNT SPENT
LAST YEAR

$

AMOUNT SPENT
THIS YEAR

$

I. INTEREST ON MORTGAGE AND OTHER LOANS

(Not payment on principal)

17. TOTAL EXPENSES

$

18A. PROVIDE THE TOTAL ACREAGE OWNED BY YOU

$
18B. IS YOUR PRIMARY RESIDENCE LOCATED ON THE ACREAGE YOU OWN?
YES

18C. HOW MANY OF THE ACRES YOU OWN ARE CONSIDERED PART OF
YOUR PRIMARY RESIDENCE?

NO

(If "Yes", complete Items 18C and 18D)

18D. WHAT IS THE SPECIFIC VALUE OF THE ACREAGE RELATED TO YOUR
PRIMARY RESIDENCE?
$

19. ACREAGE IN CROPS AND PASTURE
(A) KIND

(Grain, hay, cotton, tobacco, etc.)

20. LIVESTOCK INFORMATION

NUMBER OF ACRES
(B) LAST YEAR

(C) THIS YEAR

(A) KIND

(Cattle, pigs, sheep, ducks, etc.)

(B) TOTAL NUMBER
ON FARM NOW

PASTURE
21. DO YOU RENT YOUR FARM TO OR FROM SOMEONE ELSE?
YES

NO

(If "Yes", furnish a copy of your farm rental agreement or lease or a statement setting forth in detail particulars of the agreement)

22. REMARKS (If any)

VA FORM 21P-4165, XXX 20XX

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22. REMARKS (If any - continued)

SECTION IV: CERTIFICATION AND SIGNATURE OF CLAIMANT
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
23A. SIGNATURE OF CLAIMANT (Sign in ink)

23B. DATE SIGNED (MM/DD/YYYY)

SECTION V: WITNESSES TO SIGNATURE OF CLAIMANT IF MADE BY "X" MARK
Signature made by mark must be witnessed by two persons to whom the person making the statement is personally known, and the signatures and
addresses of such witnesses must be shown below.
24A. SIGNATURE OF WITNESS (Sign in ink)

24B. PRINTED NAME AND ADDRESS OF WITNESS

25A. SIGNATURE OF WITNESS (Sign in ink)

25B. PRINTED NAME AND ADDRESS OF WITNESS

FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged,
allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits
under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you a fee for assisting in seeking further review of a claim for VA benefits only after VA
has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of
Federal Regulations 1.526 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status and personnel
administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your response is required to obtain or retain benefits. You are required to provide the Social Security number requested under 38 U.S.C. 5101 (c)(1). VA May disclose Social Security
numbers as authorized under the Privacy Act, and specifically may disclose them for the purposed stated above. Information that you furnish may be utilized in computer matching programs
with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your
participation in any benefit program administered by the Department of Veterans Affairs.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 2900-0095, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 30 minutes per
respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance
Officer at vapra@va.gov. Please refer to OMB Control No. 2900-0095 in any correspondence. Do not send your completed VA Form 21P-4165 to this email address

VA FORM 21P-4165, XXX 20XX

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