Fillable Va Form 21-4170 - Statement Of Marital Relationship printable pdf download

OMB Control No. 2900-0114

Respondent Burden: 25 Mins.

VA DATE STAMP

STATEMENT OF

(DO NOT WRITE

MARITAL RELATIONSHIP

IN THIS SPACE)

PRIVACY ACT INFORMATION: 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 38, Code of Federal Regulations 1.576 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 Vocational Rehabilitation and Employment Records - VA,

and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN

account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). VA will not

deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal

Statute of law in effect prior to January 1, 1975, and still in effect. 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: We need this information to determine eligibility for additional benefits as a spouse of a veteran or eligibility for pension or

dependency and indemnity compensation as the surviving spouse of a veteran (38 U.S.C. 101, 103, and 1102). We estimate that you will need an average of

25 minutes to review the instructions, find the information and complete this form. VA cannot conduct or sponsor a collection of information unless a valid

OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers

can be located on the OMB Internet Page at If desired, you can call 1-800-827-1000 to get information on where to

send comments or suggestions about this form.

INSTRUCTIONS: This form is to be completed by the veteran (if living) and the person who is claiming to be the spouse or surviving spouse. Note: For the

purposes of this form, the person who is claiming to be the spouse or surviving spouse is referred to as "spouse or surviving spouse." Print all answers clearly.

Your answer to every question is important to help us complete your claim. If you do not know the answer, write "unknown." For additional space, use Item

14, "Remarks, " or attach a separate sheet, indicating the item number to which the answers apply.

IMPORTANT INFORMATION: Submit any documents that show the veteran and the spouse or surviving spouse as husband and wife; for example, lease

agreements, joint bank statements, utility bills, tax returns, insurance forms, employment records, and any other documents showing marital status. Original

documents will be returned to you.

SECTION I - INFORMATION ABOUT THE VETERAN AND THE SPOUSE OR SURVIVING SPOUSE

(First, middle, last)

2. VA FILE NUMBER

(First, middle, last)

1. NAME OF VETERAN

3. NAME OF SPOUSE OR SURVIVING SPOUSE

C/SS -

(Number and street or rural route,

4. SOCIAL SECURITY NUMBER

5. DATE OF BIRTH OF SPOUSE OR

6. COMPLETE ADDRESS OF VETERAN OR CLAIMANT

OF SPOUSE OR SURVIVING

(Month, day,

city or P. O., State and ZIP Code)

SURVIVING SPOUSE

SPOUSE

year)

SECTION II - INFORMATION ABOUT THE CLAIMED MARITAL RELATIONSHIP

(Include number and street or rural route, city or P. O.,

7A. DATE YOU BEGAN LIVING AS HUSBAND

7B. PLACE YOU BEGAN LIVING AS HUSBAND AND WIFE

Month, day, year)

State and ZIP Code)

AND WIFE (

(First, middle, last)

7C. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS HUSBAND AND WIFE

8. WHAT DID YOU AGREE YOUR RELATIONSHIP WOULD BE AT THE

7D. TO BE COMPLETED BY THE SPOUSE OR SURVIVING SPOUSE:

TIME YOU BEGAN LIVING TOGETHER?

AFTER YOU BEGAN LIVING WITH THE VETERAN, DID YOU USE HIS/HER LAST NAME?

ALWAYS

SOMETIMES

NEVER

9A. HAVE (HAD) YOU LIVED TOGETHER CONTINUOUSLY FROM THAT TIME UNTIL THIS DATE (OR THE VETERAN'S DEATH)?

(If "Yes," go to Item 10. If "No," complete Item 9B)

YES

9B. LIST ALL PERIODS OF SEPARATION

BEGINNING DATE

ENDING DATE

REASON FOR SEPARATION

(Month, day, year)

10. LIST ALL PERIODS OF TIME AND PLACES WHERE YOU LIVED AS HUSBAND AND WIFE

BEGINNING DATE

ENDING DATE

(Street address, city, and State)

ADDRESS

(Month, day, year)

VA FORM

EXISTING STOCKS OF VA FORM 21-4170, OCT 2004,

21-4170

JUL 2011

WILL BE USED.

Va Form 21-4170 - Statement Of Marital Relationship

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