Va Form 21-4182 - Application For Dependency And Indemnity Compensation Or Death Pension (Including Accrued Benefits And Death Compensation Where Applicable) From The Department Of Veterans Affairs

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APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION OR DEATH PENSION

(INCLUDING ACCRUED BENEFITS AND DEATH COMPENSATION WHERE APPLICABLE) FROM THE

DEPARTMENT OF VETERANS AFFAIRS

(Supplement to Social Security Application Forms SSA-4, 5, 7 and 10)

(Type or print)

1B. VETERAN'S SOCIAL SECURITY NUMBER

(DO NOT WRITE IN THIS SPACE)

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

(Type or print)

(Check one)

2A. FIRST - MIDDLE - LAST NAME OF CLAIMANT

2B. RELATIONSHIP TO VETERAN

WIDOW

CHILD

PARENT

WIDOWER

3A. IF VETERAN PREVIOUSLY APPLIED TO VA FOR ANY BENEFITS,

INSERT VA FILE NUMBER, IF KNOWN

SURVIVING

DIVORCE SPOUSE

IDENTIFICATION AND SERVICE INFORMATION OF VETERAN

4. DATE OF BIRTH

5A. DATE OF DEATH

5B. PLACE OF DEATH

NOTE: The following information should be furnished for each period of the veteran's service in the Army, Navy, Air Force,

Marine Corps, or Coast Guard of the United States or service as a commissioned officer in the National Oceanic Atmospheric

Administration.

6D. GRADE, RANK OR RATING

6A. ENTERED ACTIVE SERVICE

6C. SEPARATED FROM ACTIVE SERVICE

6B. SERVICE

ORGANIZATION AND BRANCH OF

NUMBER

DATE

PLACE

DATE

PLACE

SERVICE

7. IF A VETERAN SERVED UNDER A NAME OTHER THAN THAT SHOWN IN ITEM 1, GIVE FULL NAME AND SERVICE RENDERED UNDER THAT NAME

(Sign in ink)

8B. DATE SIGNED

8A. SIGNATURE OF APPLICANT

(Include No. and street or rural route, City or P.O., State and ZIP Code)

9. ADDRESS

WITNESSES TO SIGNATURE OF CLAIMANT BY "X" MARK

NOTE: A signature by mark must be witnessed by two persons to whom the person making the statement is personally known. The witnesses must sign their names in

Items 10A and 11A and type or print their names and addresses in Items 10B and 11B.

10A. SIGNATURE OF WITNESS

11A. SIGNATURE OF WITNESS

(Type or print)

10B. NAME AND ADDRESS OF WITNESS

11B. NAME AND ADDRESS OF WITNESS

ITEMS BELOW TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION OFFICE

REMARKS

ADDRESS OF TRANSMITTING SSA OFFICE

21-4182

VA FORM

SUPERSEDES VA FORM 21-4182, NOV 2001,