Va Form 21-4103 - Information From Remarried Widow/er Page 2

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OMB Control No. 2900-0038

Respondent Burden: 20 Mins.

INFORMATION FROM REMARRIED WIDOW/ER

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) identified

in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA,

published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. The requested information is considered relevant

and necessary to determine eligibility for benefits. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is

subject to verification through computer matching programs with other agencies.

Respondent Burden: We need this information to determine eligibility for death pension for a veteran's child or children (38 U.S.C. 1542). Title 38,

United States Code, allows us to ask for this information. We estimate that you will need an average of 20 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.

IMPORTANT - Please read the instructions before completing this form.

2. VA FILE NUMBER

1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

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