Va Form 21-6898 - Application For Amounts On Deposit For Deceased Veteran

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OMB Control No. 2900-0133

Respondent Burden: 15 Mins.

APPLICATION FOR AMOUNTS ON DEPOSIT FOR DECEASED VETERAN

(First, Middle, Last - Print or type)

1. VETERAN'S NAME

2. VA FILE NUMBER

XC/XSS -

(First, Middle, Last - Print or type)

(No., Street, City, Rural Route, State and ZIP Code)

3. CLAIMANT'S NAME

4. CLAIMANT'S ADDRESS

(Check)

5. CLAIMANT'S DATE OF BIRTH

6. APPLYING

7. RELATIONSHIP OF CLAIMANT TO VETERAN

PAYER OR PERSON RESPON-

FOR

SURVIVING

SIBLE FOR EXPENSES OF

CLAIMANT

SPOUSE

CHILD

MOTHER

FATHER

LAST ILLNESS OR BURIAL

PART I - TO BE COMPLETED BY OR ON BEHALF OF ALL CLAIMANTS

List below each living relative of the veteran in the order of preference down to and including all persons in the same class of relationship as that of the claimant. Write

"None" when no surviving relative is in that class. If any of the information requested is unknown to you, write "Unknown" in the space.

8. RELATION-

NAME AND ADDRESS OF PERSON

NAME

ADDRESS

DATE OF BIRTH

SHIP TO

HAVING CUSTODY OF EACH MINOR

VETERAN

SURVIVING

SPOUSE

B. MINOR