Va Form 21-4171 - Supporting Statement Regarding Marriage Page 2
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214A. HAD/HAVE THE VETERAN AND THE CLAIMANT LIVED TOGETHER CONTINUOUSLY?
(If "Yes," complete Item 14B)
NO
YES
14B. EXPLANATION
15A. HAD/HAS THE VETERAN EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
(If "Yes," complete Item 15B)
NO
YES
15B. OTHER MARRIAGES OF VETERAN
HOW MARRIAGE
DATE AND PLACE
TYPE OF MARRIAGE
DATE AND PLACE
TO WHOM MARRIED
ENDED
OF MARRIAGE
(Ceremonial, etc.)
MARRIAGE ENDED
(Death, divorce, etc.)
16A. HAS THE CLAIMANT EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
(If "Yes," complete Item 16B)
NO
YES
16B. OTHER MARRIAGES OF CLAIMANT
HOW MARRIAGE
DATE AND PLACE
TYPE OF MARRIAGE
DATE AND PLACE
TO WHOM MARRIED
ENDED
OF MARRIAGE
(Ceremonial, etc.)
MARRIAGE ENDED
(Death, divorce, etc.)
17. REMARKS
CERTIFICATION
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
18B. DATE SIGNED
18A. SIGNATURE
(Including Area Code)
(Including Area Code)
18D. EVENING TELEPHONE NUMBER
18C. DAYTIME TELEPHONE NUMBER
WITNESS TO SIGNATURE IF MADE BY "X" MARK
NOTE: Signature by mark must be witnessed by two persons to whom the signer is personally known and the signature and addresses of the witnesses must be entered
below.
19A. SIGNATURE OF WITNESS
19B. ADDRESS OF WITNESS
20A. SIGNATURE OF WITNESS
20B. ADDRESS OF WITNESS
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false.
VA FORM 21-4171, JUN 2011
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