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 8

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SECTION V: VETERAN'S PARENT
(COMPLETE ONLY IF CLAIMING BENEFITS AS THE PARENT OF VETERAN)
(Skip to Section VI if you are NOT claiming benefits as the parent of a veteran)
30A. WHAT IS YOUR MARITAL STATUS? (Check one)
MARRIED AND LIVE WITH
MARRIED AND LIVE WITH SPOUSE WHO
SEPARATED, MARRIED BUT
OTHER PARENT OF VETERAN
IS NOT THE OTHER PARENT OF THE VETERAN
NOT LIVING WITH SPOUSE
DIVORCED
WIDOWED
NEVER MARRIED
30B. IF YOUR MARRIAGE HAS ENDED, PLEASE SPECIFY THE DATE (month, day, year) AND HOW MARRIAGE ENDED (death, divorce)
30C. IF YOU ARE SEPARATED, WHAT WAS THE CAUSE OF THE SEPARATION? GIVE THE REASON, DATE(S) AND DURATION OF THE SEPARATION (IF THE
SEPARATION WAS BY COURT ORDER, ATTACH A COPY OF THE ORDER)
31A. WHAT IS YOUR SPOUSE'S NAME? (First, middle initial, last name)
31B. WHAT IS YOUR SPOUSE'S DATE
31C. WHAT IS YOUR SPOUSE'S SOCIAL
(Skip to Item 32A if never married or no longer married)
OF BIRTH? (MM,DD,YYYY)
SECURITY NUMBER?
31D. IS YOUR SPOUSE ALSO A VETERAN?
31E. WHAT IS YOUR SPOUSE'S VA FILE NUMBER? (If applicable)
YES
NO
(If "Yes," complete Item 31E)
32A. WAS THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR
32B. DATE(S) OF PARENTAL CONTROL (If veteran did not live in your household
PARENTAL CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE AGE
continuously before age 18 provide the time period (dates) when he/she was
OF MAJORITY (AGE 18 IN MOST STATES)?
under your parental control)
YES
NO
(If "Yes," skip to Item 34)
(MM DD YYYY)
to ( MM DD YYYY)
(MM DD YYYY)
to ( MM DD YYYY)
32C. WHY WASN'T THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE
AGE OF MAJORITY? (Explain fully)
33. NAME AND ADDRESS OF EACH PERSON WHO ASSUMED PARENTAL CONTROL OVER THE VETERAN OUTSIDE THE DATE(S) SHOWN IN ITEM 32B
A. NAME (FIRST, MIDDLE, LAST)
B. ADDRESS
Street address, rural route, or P.O. Box
Apt. number
City
State
ZIP Code
Country
Street address, rural route, or P.O. Box
Apt. number
City
State
ZIP Code
Country
34. IF YOU ARE NOT THE BIOLOGICAL PARENT OF THE VETERAN, PROVIDE THE NAMES OF THE BIOLOGICAL PARENTS, IF DECEASED, PROVIDE THE DATE
OF DEATH.
A. NAME (FIRST, MIDDLE, LAST)
B. DATE OF DEATH (MM,DD,YYYY)
SECTION VI: DIC
(COMPLETE ONLY IF CLAIMING DEPENDENCY AND INDEMNITY COMPENSATION (DIC))
(Skip to Section VII if you are NOT claiming DIC)
35. WHAT BENEFIT ARE YOU CLAIMING?
DIC
DIC under 38 U.S.C. 1151 (RARE)
36. LIST ANY VA MEDICAL CENTERS WHERE THE VETERAN RECEIVED TREATMENT PERTAINING TO YOUR CLAIM AND PROVIDE TREATMENT DATES:
A. NAME AND LOCATION OF VA MEDICAL CENTER
B. DATE(S) OF TREATMENT
Page 8
VA FORM 21P-534EZ, JUL 2015

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