Va Form 21p-534ez - Notice To Survivor Of Evidence Necessary To Substantiate A Claim For Dependency And Indemnity Compensation, Death Pension, And/or Accrued Benefits Page 6

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OMB Control No. 2900-0004
Respondent Burden: 25 minutes
Expiration Date: 07/31/2018
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)
APPLICATION FOR DIC, DEATH PENSION,
AND/OR ACCRUED BENEFITS
IMPORTANT: Please read the Privacy Act and Respondent Burden on page 11 before completing the form.
SECTION I: PERSONAL INFORMATION
(MUST COMPLETE)
3. VETERAN'S DATE OF BIRTH
1. VETERAN'S NAME (Last, first, middle)
2. VETERAN'S SOCIAL SECURITY NUMBER
(MM,DD,YYYY)
5. HAS THE VETERAN, SURVIVING SPOUSE, CHILD, OR PARENT EVER
4. VETERAN'S SEX
6. VA FILE NUMBER
FILED A CLAIM WITH VA?
MALE
FEMALE
YES
NO
(If "Yes," provide the file number in Item 6)
7. DID THE VETERAN DIE WHILE ON ACTIVE DUTY?
8. WHAT IS THE VETERAN'S DATE OF DEATH? (MM,DD,YYYY)
YES
NO
9. WHAT IS YOUR NAME? (First, middle, last name)
10. WHAT IS YOUR RELATIONSHIP TO THE VETERAN? (Check one)
SURVIVING SPOUSE
PARENT
CHILD
CUSTODIAN FILING FOR CHILD
12. WHAT IS YOUR DATE OF BIRTH?
11. WHAT IS YOUR SOCIAL SECURITY NUMBER?
13. ARE YOU A VETERAN?
(MM,DD,YYYY)
YES
NO
14A. WHAT IS YOUR ADDRESS?
14B. YOUR TELEPHONE NUMBER(S) (include Area Code)
DAYTIME
(
)
Street address, rural route, or P.O. Box
Apt. number
EVENING
(
)
City
State
ZIP Code
Country
CELL PHONE
(
)
15A. YOUR PREFERRED E-MAIL ADDRESS (If applicable)
15B. YOUR ALTERNATE E-MAIL ADDRESS (If applicable)
16. WHAT ARE YOU CLAIMING? (Check all that apply)
DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
DEATH PENSION
ACCRUED BENEFITS
SECTION II: VETERAN'S SERVICE INFORMATION
(COMPLETE ONLY IF THE VETERAN WAS NOT RECEIVING VA COMPENSATION OR
PENSION BENEFITS AT THE TIME OF DEATH)
(Skip to Section III if the veteran was receiving VA compensation or pension benefits at the time of his or her death)
17A. DID THE VETERAN SERVE UNDER ANOTHER NAME?
17B. PLEASE LIST OTHER NAME(S) THE VETERAN SERVED UNDER:
YES
NO
(If "Yes," complete Item 17B)
(If "No," skip to Item 18A)
18C. RELEASE DATE FROM ACTIVE SERVICE
18A. VETERAN ENTERED ACTIVE SERVICE ON (MM,DD,YYYY)
18B. BRANCH OF SERVICE
(MM,DD,YYYY)
18D. DID THE VETERAN SERVE IN A COMBAT ZONE SINCE 9-11-2001?
18E. PLACE OF LAST SEPARATION
YES
NO
19A. WAS THE VETERAN ACTIVATED TO FEDERAL ACTIVE DUTY UNDER AUTHORITY OF
19B. DATE OF ACTIVATION (MM,DD,YYYY)
TITLE 10, U.S.C. (National Guard)?
YES
NO
(If "Yes," answer Items 19B, 19C and 19D)
19C. WHAT IS THE NAME AND ADDRESS OF THE VETERAN'S RESERVE/NATIONAL GUARD UNIT?
19D. WHAT IS THE TELEPHONE NUMBER OF THE
RESERVE/NATIONAL GUARD UNIT?
(Include Area Code)
(
)
20A. WAS THE VETERAN EVER A PRISONER OF WAR?
20B. DATES OF CONFINEMENT
FROM:
TO:
YES
NO
(If "Yes," complete Item 20B)
(If "No," skip to Section III)
21P-534EZ
VA FORM
SUPERSEDES VA FORM 21-534EZ, JUN 2014,
Page 6
JUL 2015
WHICH WILL NOT BE USED.

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