Va Form 21-535 - Application For Dependency And Indemnity Compensation By Parent(S) Page 3
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10OMB Control No. 2900-0005
Respondent Burden: 1 hour and 12 minutes
DO NOT WRITE IN
THIS SPACE
(VA DATE STAMP)
Application for Dependency and Indemnity Compensation by Parent(s) (Including Accrued
Benefits and Death Compensation when Applicable), VA Form 21-535
Please read the attached "General Instructions" before you fill out this form.
1. Did the veteran ever file a claim with VA?
2. What is the VA file number?
SECTION
I
Yes
No
(If "Yes," answer Item 2)
Tell us what you
3. Have you ever filed a claim with VA?
4. What is the VA file number?
and the deceased
(If "Yes," answer Items 4
Yes
No
veteran have
through 6)
applied for
5. Based on whose service was the claim filed?
First
Middle
Last
6. What is your relationship to that person?
SECTION
7. What is the veteran's name?
II
First
Middle
Last
Suffix (If applicable)
Tell us
8. What is the veteran's Social Security number (SSN)? 9a. Did the veteran serve under another name?
about you
Yes
No
(If "Yes," answer Item 9b)
and the
deceased
9b. Please list the other name(s) the veteran
10. What is the veteran's date of birth?
veteran
served under
mo day yr
Attach a copy of the
11. What is the veteran's date of death?
death certificate unless
mo day yr
the veteran died while
serving in the Army,
12. What is your name?
Navy, Air Force,
Note: If both parents of the veteran are jointly claiming benefits, provide both full names.
Marine Corps, or Coast
Guard, or as a
Mother:
commissioned officer in
First
Middle
Last
the National Oceanic
Father:
and Atmospheric
Administration, Coast
First
Middle
Last
and Geodetic Survey,
13. What is your address?
Environmental Science
Services
Administration, or
Street address, Rural Route, or P.O. Box
Apt. number
Public Health Service,
or in a hospital or
City
State
ZIP Code
Country
institution under the
control of the U.S.
15. What is your e-mail address?
14. What are your telephone numbers?
government.
(Include Area Code)
Daytime
Evening
16. What is your Social Security number?
17. What is your date of birth?
Note: If both parents of the veteran are jointly
Note: If both parents of the veteran are jointly
claiming benefits, provide both dates of birth.
claiming benefits, provide both SSNs.
Mother
Father
Mother:
Father:
mo day yr
mo day yr
VA FORM
EXISTING STOCK OF VA FORM 21-535, APR 2005,
21-535
page 1
21-535
FEB 2012
WILL BE USED.
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