Fillable Va Form 21-4171 - Supporting Statement Regarding Marriage printable pdf download

OMB Control No. 2900-0115

Respondent Burden: 20 Minutes

VA DATE STAMP

(DO NOT WRITE IN THIS

SPACE)

SUPPORTING STATEMENT REGARDING MARRIAGE

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, published in

the Federal Register. Your obligation to respond is voluntary. The requested information is considered relevant and necessary to

determine maximum benefits under the law. 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 benefits based on a marital relationship between the

claimant and the veteran (38 U.S.C. 101, 103, and 1102). 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 and give your comments or ask

for mailing information on where to send your comments.

INSTRUCTIONS: Please complete all items. Your answer to every question is important to help us complete the claimant's claim. If you do not know the answer, write

"unknown." For additional space, use Item 17, "Remarks," or attach a separate sheet, indicating the item number to which the answers apply.

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

3. FIRST NAME - MIDDLE NAME - LAST NAME OF

2. FILE NUMBER

(SPOUSE OR SURVIVING SPOUSE)

CLAIMANT

C/CSS-

4A. NAME OF PERSON COMPLETING THIS FORM

4B. ADDRESS OF PERSON COMPLETING THIS FORM

I understand that this statement will be considered in connection with an application for VA benefits based on a marital relationship between the veteran and the person

named in Item 3.

5B. WHAT WAS / IS YOUR

6A. HOW LONG HAD/HAVE

5A. WHAT WAS/IS YOUR RELATIONSHIP

6B. HOW LONG HAD / HAVE

RELATIONSHIP TO THE

YOU KNOWN THE

(Parent, child,

TO THE VETERAN?

CLAIMANT? (Parent, child,

(Months,

(Months, years)

VETERAN?

CLAIMANT?

brother, sister, etc. If not related, state

years)

brother, sister, etc. If not related,

"None")

state"None")

7A. HOW OFTEN HAD/HAVE YOU MET THE VETERAN?

7B. ON WHAT OCCASION(S) HAD/HAVE YOU MET THE VETERAN?

7C. HOW OFTEN HAVE YOU MET THE CLAIMANT?

7D. ON WHAT OCCASIONS HAVE YOU MET THE CLAIMANT?

8. WERE/ARE THE VETERAN AND THE CLAIMANT GENERALLY

9. DID/DO EITHER THE VETERAN OR CLAIMANT EVER DENY THE

MARRIAGE?

KNOWN AS HUSBAND AND WIFE?

YES

(If

10A. DID/DO YOU CONSIDER THE VETERAN AND THE CLAIMANT TO

10B. FACT AND REASONS FOR SUCH BELIEF "REMARKS"

necessary use section on reverse and key answers to item number)

BE HUSBAND AND WIFE?

(If "Yes," complete Item 10B

)

YES

11. NAME(S) BY WHICH CLAIMANT WAS/IS KNOWN

LAST NAME

FIRST NAME

12A. HAD/HAVE YOU EVER HEARD THE VETERAN OR THE CLAIMANT REFER TO EACH OTHER AS HUSBAND AND WIFE?

(If "Yes," complete Items 12B and 12C)

YES

12B. DATE

12C. PLACE

13A. DID/DO THE VETERAN AND THE CLAIMANT MAINTAIN A HOME AND LIVE TOGETHER AS HUSBAND AND WIFE?

(If "Yes," complete Item 13B)

YES

13B. PERIODS OF TIME AND PLACES WHERE THE VETERAN AND THE CLAIMANT HAD/HAVE LIVED TOGETHER

BEGINNING DATE

ENDING DATE

CITY OR TOWN

STATE

EXISTING STOCKS OF VA FORM 21-4171, NOV 2004,

VA FORM

21-4171

WILL BE USED.

JUN 2011

Va Form 21-4171 - Supporting Statement Regarding Marriage

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