Va Form 21-4103 - Information From Remarried Widow/er

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INSTRUCTIONS FOR
INFORMATION FROM REMARRIED WIDOW/ER
VA FORM 21-4103
NOTE: Read very carefully, detach, and keep this instruction sheet for your reference.
A. How can I contact VA if I have questions?
Income
If you have questions about this form, how to fill it out, or
Payments from any source will be counted, unless the law says
about benefits, contact your nearest VA regional office. You
that they don't need to be counted. Report all income, and VA
can locate the address of the nearest regional office in your
will determine any amount that does not count. Be sure to
telephone book blue pages under "United States Government,
report the total amounts before you take out deductions for
Veterans" or call 1-800-827-1000 (Hearing Impaired TDD
taxes, insurance, etc. If you expect to receive a payment, but
line 1-800-829-4833). You may also contact VA by Internet
you don't know how much it will be, write "unknown" in the
at
space. If you do not receive any payments from one of the
sources that we list, write "0" or "none" in the space.
B. What is the purpose of VA Form 21-4103?
If a surviving spouse is no longer eligible to receive death
Net Worth
pension, use VA Form 21-4103 to apply for death pension on
behalf of a child or children of the veteran.
Net worth is the market value of all interest and rights you,
your spouse and the child(ren) have any kind of property less
any mortgages or other claims against the property. However,
C. Who may be eligible for death pension?
net worth does not include the house you live in or a
Pension may be paid for the veteran's biological children,
reasonable area of land it sits on. Net worth also does not
adopted children, and stepchildren. But these children must be
include the value of personal things used everyday like your
unmarried and:
vehicle, clothing, and furniture.
The net worth must be
reported for the person legally responsible for the child(ren)'s
under age 18, or
support and all child(ren) for whom benefits are claimed.
between 18 and 23 and pursuing an approved course of
education, or
of any age if they became permanently unable to support
In order to determine entitlement to pension, the surviving
themselves before reaching age 18.
spouse must report:
If any child is claimed as permanently unable to support
All his/her income and net worth, and
themselves before reaching age 18, furnish a statement from
All the income and net worth of his/her spouse from the
an attending physician or other medical evidence which shows
date of remarriage, and
the nature and extent of the physical or mental impairment.
All the income and net worth of each child for whom
benefits are claimed.
If a child who is receiving death pension marries, then VA
E. How do I complete my application?
will no longer pay pension. However, VA may begin paying
pension again if the child's marriage is terminated.
Print all answers clearly. If an answer is "none" or "0," write
that. Your answer to every question is important to help us
D. How does VA decide whether or not a child is eligible
complete your claim. If you do not know the answer, write
to receive death pension?
"unknown." For additional space, use Item 13, "Remarks," or
attach a separate sheet, indicating the item number to which
VA pays pension based on the amount of income and net
the answers apply. Make sure you sign and date this
worth of the child or children and the person or persons legally
application.
responsible for the child's or children's support. This is based
on law. VA must include as income all sources that federal
F. What do I do when I have completed my application?
law specifies. You can find out what the current income
When you have completed this application mail it or take it to
limitations and rates of benefits are by contacting your nearest
a VA regional office. Be sure to attach any materials that
VA office.
support and explain your claim. Also, make a photocopy of
your application and everything that you submit to VA before
you mail it.
EXISTING STOCK OF VA FORM 21-4103, JAN 2005,
VA FORM
21-4103
JUN 2011
WILL BE USED.

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