Va Form 21-535 - Application For Dependency And Indemnity Compensation By Parent(S) Page 5
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1023a. Was the veteran a member of your household
23b. Date of parental control.
SECTION IV (Continued)
or under your parental control at all times
to
before he/she reached the age of majority?
Tell us about
mo day yr
mo day yr
the veteran's
Yes
No
to
parents
(If "NO," answer Items 23b through 23d.)
mo day yr
mo day yr
23c. Why wasn't the veteran a member of your household or under your parental control at all times
before he/she reached the age of majority? (Explain fully)
23d. Name and address of each person who assumed parental control over the veteran outside the
date(s) shown in item 23b.
First
Middle
Last
First
Middle
Last
24. What is your marital status? (Check one)
SECTION
Tell us about
Married and live with other parent of veteran
V
your marital
history
Married and live with spouse who is not the other parent of veteran
What was the date of
Separated, married but not living with spouse
separation?
mo day yr
What was the cause of the separation? Give the reason, date(s), and duration of the separation. If
the separation was by court order, attach a copy of the order.
What was the date of
Divorced
divorce?
mo day yr
What was the date of
Widowed
your spouse's death?
mo day yr
Never married
If never married, skip to Section VI.
25. What is your spouse's name?
First
Middle
Last
26. What is your spouse's date of birth?
27. What is your spouse's Social Security number?
mo day yr
28a. Is your spouse also a veteran?
28b. What is your spouse's VA file number (if any)?
Yes
No
(If "Yes," answer Item 28b also)
21-535
page 3
VA FORM 21-535, FEB 2012
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