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 7

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SECTION III: MARITAL INFORMATION (COMPLETE ONLY IF CLAIMING BENEFITS AS

THE SURVIVING SPOUSE OF THE VETERAN)

(Skip to Section IV if you are NOT claiming benefits as the surviving spouse of the veteran)

TELL US ABOUT THE VETERAN'S MARRIAGES

21A. HOW MANY TIMES WAS THE VETERAN MARRIED (including marriage to you)?

21D. TYPE OF MARRIAGE

21F. DATE (month, day, year) and

21B. DATE (month, day, year) and PLACE

21C. TO WHOM MARRIED

21E. HOW MARRIAGE

(ceremonial, common-law,

PLACE MARRIAGE TERMINATED

OF MARRIAGE (city, state or country)

(first, middle, last name)

TERMINATED

proxy, tribal, or other)

(city/state or country)

(death, divorce)

21G. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 21D, PLEASE EXPLAIN:

TELL US ABOUT YOUR MARRIAGES

22B. HOW MANY TIMES HAVE YOU BEEN MARRIED? (including your marriage to the

22A. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?

veteran)

YES

22F. HOW MARRIAGE

22G. DATE (month, day, year)

22E. TYPE OF MARRIAGE

22C. DATE (month, day, year) and PLACE

22D. TO WHOM MARRIED

TERMINATED

and PLACE MARRIAGE

(ceremonial, common-law,

OF MARRIAGE (city/state or country)

(first, middle, last name)

(death, divorce, marriage has not

TERMINATED

proxy, tribal, or other)

been terminated)

(city/state or country)

22H. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22E, PLEASE EXPLAIN:

23. WAS A CHILD BORN TO YOU AND THE VETERAN DURING YOUR MARRIAGE

24. ARE YOU EXPECTING THE BIRTH OF THE VETERAN'S CHILD?

OR PRIOR TO YOUR MARRIAGE?

YES

25. DID YOU LIVE CONTINUOUSLY WITH THE VETERAN FROM THE DATE

26. WHAT WAS THE CAUSE OF SEPARATION? GIVE THE REASON, DATE(S) AND

OF MARRIAGE TO THE DATE OF HIS/HER DEATH?

DURATION OF THE SEPARATION (IF THE SEPARATION WAS BY COURT ORDER,

ATTACH A COPY OF THE ORDER)

YES

(If "No," complete Item 26)

27. AT THE TIME OF YOUR MARRIAGE TO THE VETERAN, WERE YOU AWARE OF ANY REASON THE MARRIAGE MIGHT NOT BE LEGALLY VALID?

YES

(If "Yes," provide explanation):

SECTION IV: DEPENDENT CHILDREN

(COMPLETE ONLY IF CLAIMING BENEFITS FOR A CHILD(REN) OF THE VETERAN)

(Skip to Section V if you are NOT claiming benefits for a child(ren) of the veteran)

28B. DATE (month, day,

(Check all that apply)

28C. SOCIAL

28A. NAME OF CHILD

year) and PLACE OF

28G.

28H.

28I.

28J. CHILD

SECURITY

28D.

28E.

28F.

(First, middle initial, last name)

BIRTH

18-23 YEARS

SERIOUSLY

CHILD

PREVIOUSLY

NUMBER

BIOLOGICAL

ADOPTED

STEPCHILD

(city/state or country)

OLD (in school)

DISABLED

MARRIED

If claiming benefits as the surviving spouse or custodian filing for a child, in items 29A through 29D tell us about the children listed in Item 28A who do

not live with you.

29B. CHILD'S COMPLETE ADDRESS

29D. MONTHLY AMOUNT YOU

29A. NAME OF CHILD

29C. NAME OF PERSON THE CHILD

(Number and street or rural route, city or P.O., city,

CONTRIBUTE TO THE CHILD'S

(First, middle initial, last name)

LIVES WITH (If applicable)

State, ZIP Code and country)

SUPPORT

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