Va Form 21-534a - Application For Dependency And Indemnity Compensation By A Surviving Spouse Or Child
Download a blank fillable Va Form 21-534a - Application For Dependency And Indemnity Compensation By A Surviving Spouse Or Child in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 21-534a - Application For Dependency And Indemnity Compensation By A Surviving Spouse Or Child with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2OMB. Approved No. 2900-0004
Respondent Burden: 15 Mins.
APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION
BY A SURVIVING SPOUSE OR CHILD
- IN-SERVICE DEATH ONLY
Privacy Act Notice: 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 VA.
Respondent Burden: We need this information to determine eligibility for service connected death benefits under 38 U.S.C. 1310 through 1314. Title 38, United States Code, allows us to
ask for this information. We estimate that you will need an average of 15 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.
1. VETERAN'S FIRST - MIDDLE- LAST NAME
2. VETERAN'S SOCIAL SECURITY NO.
3. CLAIMANT'S FIRST - MIDDLE- LAST NAME
4. CLAIMANT'S SOCIAL SECURITY NO.
NOTE: When you file this application, you are telling us that you elect to receive Dependency and Indemnity Compensation (DIC) and all other
service-connected death benefits to which you and/or the deceased veteran's children may be entitled.
5. FOR SURVIVING SPOUSE
I
have
have not
lived continuously with the veteran from date of marriage to date of death.
ONLY: If not, answer Item 6.
7. DATE OF BIRTH OF SURVIVING
6. CAUSE OF SEPARATION (Give reason, date of separation, and duration of separation. If separation was by Court order,
SPOUSE (Mo., Day, Yr.)
attach a copy of such order.)
8. CHILDREN OF THE DECEASED VETERAN (Natural, Step or Adopted) IN MY CUSTODY
DATE OF BIRTH
SOCIAL SECURITY
PLACE OF BIRTH
FULL NAME
RELATIONSHIP TO CLAIMANT
(Mo., Day, Yr.)
NUMBER
(City and State)
9. CLAIMANT'S CURRENT MAILING ADDRESS
10. CLAIMANT'S TELEPHONE NUMBERS (Including Area Code)
EVENING
DAYTIME
11. I
will
will not be changing my address.
13. DATE OF ADDRESS CHANGE
12. CLAIMANT'S NEW ADDRESS
do not want my VA payment to be directly deposited to my financial account.
want
14. I
15. ACCOUNT
ACCOUNT NUMBER
CHECKING
FINANCIAL INSTITUTION'S NINE-DIGIT ROUTING OR TRANSIT NUMBER
SAVING
I CERTIFY THAT the foregoing statements are true and complete to the best of my knowledge and belief.
16. SIGNATURE OF CLAIMANT
17. DATE SIGNED
18. NAME AND RANK OF MILITARY
19. TELEPHONE NUMBER OF CAO
20. E-MAIL ADDRESS OF CAO
CASUALTY ASSISTANCE OFFICER (CAO)
PENALTY - The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a
material fact knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
21-534a
VA FORM
EXISTING STOCKS OF VA FORM 21-534A, MAR 2004,
OCT 2011
WILL BE USED.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21-534a - Application For Dependency And Indemnity Compensation By A Surviving Spouse Or Child - In-service Death Only
Legal
Va Form 21-4182 - Application For Dependency And Indemnity Compensation Or Death Pension (including Accrued Benefits And Death Compensation Where Applicable) From The Department Of Veterans Affairs
Legal
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
Legal
Va Form 21-526e - Application For Disability Compensation And Related Compensation Benefits Template
Legal
Va Form 26-1817 - Request For Determination Of Loan Guaranty Eligibility - Unmarried Surviving Spouses
Legal
Related Categories
Parent category: Legal