VA Form 21-686c PDF Details

VA Form 21-686c is an essential form for service members and their spouses that provides invaluable benefits. This form allows you to add benefits to a dependent or remove someone from benefits. In this blog post, we will provide an in-depth overview of what VA Form 21-686c is, why it's important to veterans and their spouses, how to complete it correctly and accurately, and when to submit it. Read on if you have questions about submitting or filling out the crucial document.

QuestionAnswer
Form Name Va Form 21 686C
Form Length 15 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 3 min 45 sec
Other names va 21, va form 21 686c pdf, veterans administration forms 21 686c, form 21 686c

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NOTICE TO BENEFICIARY/CLAIMANT REGARDING THE INFORMATION AND EVIDENCE NEEDED TO

SUPPORT A CLAIM FOR ADDITIONAL BENEFITS FOR A DEPENDENT OR TO REMOVE A

DEPENDENT FROM AN AWARD

Use this form and the attached application to:

•submit a claim for additional benefits for a dependent, or

•request removal of a dependent from your award.

The table below identifies the types of dependents for whom VA beneficiaries may be entitled to additional benefits.

If you are a …

Then you may be entitled to additional benefits for …

 

 

 

veteran entitled to disability compensation who has a

•

a spouse,

combined disability rating of at least 30 percent

•

children under age 18,

 

• children that are between the ages of 18 and 23 who are attending school,

 

• children over age 18 that are permanently incapable of self-support, and/or

 

•

dependent parents.

 

 

 

veteran entitled to Veterans Pension

•

a spouse,

 

• children under age 18,

 

• children that are between the ages of 18 and 23 who are attending school, and/or

 

• children over age 18 that are permanently incapable of self-support

 

 

 

surviving spouse entitled to survivors benefits

•

children under age 18,

 

•

children that are between the ages of 18 and 23 who are attending school, and/or

 

•

children over age 18 that are permanently incapable of self-support.

 

Exception: A surviving spouse entitled to Dependency and Indemnity Compensation (DIC) is

 

not entitled to additional benefits for children over age 18 that receive DIC in their own right.

 

 

 

TABLE OF CONTENTS

The table below provides a guide to the instructions and the application. The completion of certain sections of this application are required. Be aware that you must complete Section I - Veteran/Claimant's Identification Information and Section X - Beneficiary/ Claimant's Certification and Signature. If these sections are not complete, we will not be able to process your claim for additional benefits for dependents. Otherwise, complete the remaining sections that apply to you.

If you are …

Instructions

Application

claiming additional benefits for a spouse

Pages 3 and 4

Pages 8 and 9

 

 

 

claiming additional benefits for a child

Pages 4 - 5

Pages 10 and 11

 

 

 

reporting a divorce

Page 5

Page 12

 

 

 

reporting that a stepchild is no longer a member of your

 

 

household

Page 6

Page 12 and 13

 

 

 

reporting the death of a

 

 

• spouse

Page 5

Page 13

• child

Page 6

 

 

 

• dependent parent

Page 6

 

 

 

 

 

 

reporting the marriage of a child

Page 6

Page 13

 

 

 

reporting that a schoolchild over 18 has stopped attending school

Page 6

Page 13

 

 

 

claiming additional benefits for more than four children

 

Addendum - Page 15

 

 

 

CIRCUMSTANCES THAT REQUIRE ADDITIONAL FORMS

 

 

Under certain circumstances, other forms in addition to VA Form 21-686c, Application Request to Add and/or Remove Dependents, must be provided when claiming additional benefits for a dependent. The table below describes those circumstances. All VA forms are available at www.va.gov/vaforms.

VA FORM 21-686c, SEP 2018

Page 1

 

If ...

Then submit ...

 

 

 

 

 

 

• you are seeking additional benefits for a child or

VA Form 21-674, Request for Approval of School Attendance.

 

 

children who are between the ages of 18 and 23

Note: Submit VA Form 21-686c in addition to VA Form 21-674 only if you

 

 

who are attending school

 

 

have never received additional benefits for the child or children.

 

 

 

 

 

 

 

 

 

• you are entitled to Veterans Pension (instead of

VA Form 21P-0516-1, Improved Pension Eligibility Verification Report

 

 

disability compensation based on service-

(Veteran With No Children), in addition to VA Form 21-686c.

 

 

connected disabilities), and

 

 

 

• you are seeking additional benefits for a spouse

 

 

 

only

 

 

 

 

 

 

 

• you are entitled to Veterans Pension

VA Form 21P-0517-1, Improved Pension Eligibility Verification Report

 

•you are seeking additional benefits for a child or (Veteran With Children), in addition to VA Form 21-686c. children (with or without a spouse), and

•the child or children are under the age of 23 or permanently incapable of self-support

• you are entitled to Survivors Pension,(instead of

VA Form 21P-0519s-1, Improved Pension Eligibility Verification Report

DIC based on a veteran's service-connected death) (Surviving Spouse With Children), in addition to VA Form 21-686c.

and

 

• you are seeking additional benefits for a child or

 

children that are either under the age of 23 or

 

incapable of self-support.

 

 

 

• you are a veteran entitled to disability

VA Form 21P-509, Statement of Dependency of Parent(s).

compensation (based on service-connected

 

disabilities), and

Note: There is no need to submit VA Form 21-686c when filing a claim for

• you are seeking additional benefits for a

additional benefits for a dependent parent or parents.

dependent parent or parents.

 

 

 

• you are a veteran entitled to disability

VA Form 21-2680, Examination for Housebound Status or Permanent Need

compensation, and

for Regular Aid and Attendance, or if your spouse resides in a nursing home,

• you are seeking additional benefits for a spouse

use VA Form 21-0779, Request for Nursing Home Information in

who requires aid and attendance

Connection with Claim for Aid and Attendance.

 

Note: Submit VA Form 21-686c in addition to one of the forms referenced

 

above only if you have never received additional benefits for your spouse.

 

 

• you are a veteran seeking additional benefits for

VA Form 21-4170, Statement of Marital Relationship, and

a spouse based on common-law marriage

VA Form 21P-4171, Supporting Statement Regarding Marriage.

 

 

Note: The above referenced forms must be submitted in addition to

 

VA Form 21-686c.

HOW TO APPLY ELECTRONICALLY

Want to apply electronically? You can apply online at www.va.gov. If you sign in or create an account at www.va.gov, we can prefill parts of your application and save your work in progress.

NOTE: You may wish to contact an accredited veteran service officer (VSO) to assist you with your application. You may locate a list of VSO's at https://www.va.gov/vso/ .

WHERE TO SEND INFORMATION AND EVIDENCE

MAIL TO

SUBMIT ONLINE

 

 

Department of Veterans Affairs

Evidence Intake Center

VA gov: www.va.gov

PO Box 4444

Direct Upload via access.va.gov

Janesville, WI 53547-4444

VA FORM 21-686c, SEP 2018

Page 2

IMPORTANT: Applicants must provide their Social Security Number (SSN), and the SSN of their dependent(s) unless a SSN has not been assigned. Use Section IX, Item 25, Remarks, to explain why a SSN has not been assigned.

TO ADD A SPOUSE TO A VETERAN'S AWARD:

Marriage by Ceremony

VA will require additional evidence* to establish a spouse; if

•you do not reside within a state, territory, or other possession of the United States,

•your entries on the application conflict with other information you provided, and the discrepancies cannot be resolved through contact with you or a review of other information of record

•information of record raises questions regarding the validity of the marriage, or

•there is an indication of fraud or misrepresentation.

*Additional Evidence:

•Primary evidence of a marriage consists of a copy or abstract of the public record of a marriage, or a copy of the church record of a marriage, containing sufficient data to identify the

•parties involved,

•date (month, day, and year) and place (city and state, county and state, or city and country) of the marriage, and

•number of prior marriages for each spouse, if not shown on the official record.

•If primary evidence of a marriage is unavailable, a marriage may still be established by submission of the following

evidence in the order of preference shown below;

•an official report from your branch of service regarding a marriage that occurred while you were in service,

•an affidavit of the clergyman or magistrate who officiated in the marriage ceremony,

•a certified copy of the original certificate of marriage,

•affidavits or certified statements signed by two or more witnesses that attended the marriage ceremony, or

•any other secondary evidence that reasonably supports the assertion that a valid marriage occurred.

Note: The process to establish a same sex or transgender marriage is no different than the process to establish a marriage between the opposite sex.

Establishing a Common-Law Marriage

In some states it is possible to contract a marriage without a ceremony and without registration of the marriage. This type of marriage is referred to as a common-law marriage.

VA may recognize a common-law marriage that was considered valid in the state in which it took place. A common law marriage generally requires an agreement between the parties to be married, cohabitation, and holding themselves out to the public as married.

Evidence that must be submitted to claim a common-law marriage:

•VA Form 21-4170 completed by the veteran

•VA Form 21-4170 completed by the veteran's spouse in the common-law marriage

•Two VA Forms 21P-4171, each completed by two different persons that can provide their personal observations about the parties to the common-law marriage and the relationship that exists/existed between them, and

•Copies of the birth certificates of any children born of the common-law marriage.

Tribal Ceremony

VA may recognize marriages performed in accordance with tribal custom.

To establish a tribal marriage, a claimant must provide all of the following items:

•Affidavits from the parties married by tribal custom that include the name of the tribe, date (month, day, and year) of marriage, place (city and state, county and state, or city and country) where the marriage ceremony occurred, and name/mailing address of the person who performed the ceremony.

•Affidavits from at least two people who were present at the time the tribal marriage ceremony took place. The affidavits must include the name of the tribe, date (month, day, and year) of marriage, place (city and state, county and state, or city and country) where the marriage ceremony occurred, and name/mailing address of the person who performed the ceremony.

•Affidavit from the person who performed the ceremony, showing the date (month, day, and year) and place (city and state, county and state, or city and country) where the marriage ceremony occurred, and that person's authority for conducting the ceremony.

VA FORM 21-686c, SEP 2018

Page 3

Proxy Marriage

A proxy marriage is a wedding in which one or both of the individuals being united are not physically present, and are instead represented by other persons. If both partners are absent, a double proxy wedding occurs.

Marriage by proxy typically occurs when a couple wishes to marry, but one or both partners cannot attend for reasons such as military service, imprisonment, or travel restrictions; or when a couple lives in a jurisdiction in which they cannot legally marry.

All documents/certificates issued in connection with a claimed proxy marriage must be provided to establish a proxy marriage for VA purposes.

Note: The validity of a proxy marriage is dependent upon the law in effect at the location in which the proxy marriage was performed.

Spousal Aid & Attendance (A&A)

•VA may pay additional benefits to a Veteran for a spouse with severe medical need/disability (ies). To claim the additional benefits, a

•Veteran must complete a VA Form 21-2680 and submit medical evidence showing his or her spouse

•is blind or so nearly blind as to have corrected visual acuity of 5/200 or less in both eyes or concentric contraction of the visual field to 5 degrees or less; or

•is a patient in a nursing home because of mental or physical incapacity (by completing VA Form 21-0779); or

•requires the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing, attending to the wants of nature, adjusting prosthetic devices, or protecting him or her from the hazards of his or her daily environment.

TO ADD A CHILD TO A BENEFICIARY/CLAIMANT'S AWARD:

Unmarried Child

A person must be unmarried in order to be considered a child for VA purposes.

VA may continue paying additional benefits for an unmarried child

•until the child reaches age O 18, or

O 23, if the child is attending an approved school, or

•indefinitely if the child becomes permanently incapable of self-support before his/her 18th birthday.

VA will require a copy of the child's birth certificate; if

•you do not reside within a state, territory or other possession of the United States,

•your entries on the application conflict with other information you provided, and the discrepancies cannot be resolved through contact with you or a review of other information of record, or

•there is an indication of fraud or misrepresentation.

School-Age Child

You must complete and submit VA Form 21-674 to claim additional benefits for a child who is

•between the ages of 18 and 23, and

•attending school.

Note:

•Claimants with more than one school-age child must complete a separate VA Form 21-674 for each child.

•VA Form 21-674 is used to report

Oschool attendance,

Oa change in the educational facility a child is attending, and/or

Oa change in the date a school-age child plans to stop attending school.

Stepchild

VA will ask you to provide a copy of your stepchild's birth certificate, showing the names of both parents, before it will add the stepchild; if

•you do not reside within a state, territory, or other possession of the United States,

•your entries on the application conflict with other information you provided, and the discrepancies cannot be resolved through contact with you or a review of other information of record.

VA FORM 21-686c, SEP 2018

Page 4

•information of record raises questions regarding the validity of the marriage of the stepchild's biological or adoptive parent to the veteran, or

•there is an indication of fraud or misrepresentation.

Provide a copy of the decree of adoption or adoptive placement agreement if the veteran's spouse is the adoptive parent of the stepchild.

Note:

•VA may pay benefits to or for a stepchild only if the stepchild is (or was at the time of the veteran's death, if the veteran is deceased) a member of the veteran's household.

•If the veteran and stepchild do not reside together (or were not residing together when the veteran died, if the veteran is deceased), the stepchild remains a member of the veteran's household if

•they live (or lived, if the veteran is deceased) apart for medical reasons, to attend school, or to fulfill a military service obligation, or

•the veteran provides (or provided, if the veteran is deceased) at least half of the stepchild's support.

Adopted Child

A claim for additional benefits for an adopted child must include a copy of the

•final decree of adoption,

•adoptive placement agreement,

•interlocutory decree of adoptions, or

•revised birth certificate.

Note: VA cannot pay additional benefits for a grandchild or foster child unless the claimant submits evidence (referenced above) showing the veteran adopted the grand/foster child.

Child Incapable of Self-Support

VA may pay additional benefits for a child beyond his/her 23rd birthday if VA determines the child became permanently incapable of self-support before his/her 18th birthday.

A claim for additional benefits for a child who is incapable of self-support must include

•medical evidence showing a permanent mental or physical disability existed before his/her 18th birthday, and

•a statement from an attending physician showing the nature and extent of the child's physical or mental impairment.

REMOVAL OF A SPOUSE FROM A VETERAN'S AWARD:

Divorce or Death of a Spouse

VA must remove a spouse from a veteran's award when the spouse dies or divorces/annuls the marriage to the veteran.

Note:

•Veterans in receipt of disability compensation are not required to report to VA a separation or estrangement from their spouse, as it will have no effect on their award.

•Veterans remain entitled to additional benefits for a stepchild after divorcing the stepchild's biological or adoptive parent, as long as the veteran provides at least half of the stepchild's support.

VA FORM 21-686c, SEP 2018

Page 5

 

REMOVAL OF A CHILD FROM A BENEFICIARY'S AWARD:

Married Child

A person must be unmarried to qualify as a child for VA purposes. Therefore, a person of any age who marries ceases to be a child for VA purposes.

Note: If a child marries, and then the marriage is terminated by annulment or declared void, VA may resume the payment of additional benefits for the child.

Child Who Is Between the Ages of 18 and 23 and Not Attending School

To be considered a school child for VA purposes a person must be between the ages of 18 and 23 and attending a VA-accredited educational facility.

Stepchild

VA must remove a stepchild from a veteran's award when the stepchild ceases being a member of the veteran's household.

Note: The awarding of legal custody of a stepchild to someone other than the veteran will not affect the additional benefits to which the veteran is entitled for that child, as long as the stepchild remains a member of the veteran's household.

Child Given Up for Adoption

In most cases, a beneficiary who gives up a child for adoption is no longer entitled to additional benefits for that child.

VA will use the most beneficial effective date when removing the veteran's child that has been given up for adoption. The date (month, day, and year) that the child was given up for adoption must be provided. Use Section IX, Item 25, Remarks to provide this information.

Death of a Child

VA must remove a child from a beneficiary's award when the child dies.

REMOVAL OF A DEPENDENT PARENT DUE TO DEATH:

Dependent Parent

VA must remove a dependent parent from a veteran's award when a parent dies.

For more information on VA benefits, visit our web site at www.va.gov, contact us at https://iris.custhelp.va.gov or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the Federal relay number is 711.

VA FORM 21-686c, SEP 2018

Page 6

APPLICATION REQUEST TO ADD AND/OR

REMOVE DEPENDENTS

INSTRUCTIONS: Make sure you sign and date this form in Items 26A and 26B.

Note: Unless the claimant is the veteran's surviving spouse or a designated

"alternate signer", the veteran must sign in Item 26A. When you have completed this form,you can mail it to the address shown at the bottom of Page 2. If you prefer you may complete and submit the form online at www.va.gov.

OMB Approved No. 2900-0043

Respondent Burden: 30 minutes

Expiration Date: 09/30/2021

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

SECTION I: VETERAN/CLAIMANT'S IDENTIFICATION INFORMATION

(Note: Completion of this section is REQUIRED to process your request; any omission may delay processing)

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly to help expedite processing of the form.

1.VETERAN'S NAME (First, Middle Initial, Last)

2. VETERAN'S SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If known)

4. VETERAN'S DATE OF BIRTH (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.CLAIMANT'S NAME (If other than veteran) (First, Middle Initial, Last)

6. CLAIMANT'S SOCIAL SECURITY NUMBER

7. VETERAN'S SERVICE NUMBER (If applicable) 8. TELEPHONE NUMBER (Include Area Code)

Enter International Phone

Number (If applicable)

9. E-MAIL ADDRESS (Optional)

I agree to receive electronic correspondence from VA in regards to my claim.

 

 

 

 

 

 

10.COMPLETE MAILING ADDRESS OF VETERAN/CLAIMANT (Number and Street or Rural Route, P. O. Box, City, State, ZIP Code and Country)

No. &

Street

Apt./Unit Number

State/Province

Country

City

ZIP Code/Postal Code

SECTION II: INFORMATION NEEDED TO ADD SPOUSE

11A. SPOUSE'S NAME (First, Middle Initial, Last)

11B. SPOUSE'S DATE OF BIRTH

 

MONTH

DAY

YEAR

11C. SPOUSE'S SOCIAL SECURITY NUMBER (SSN) (If your spouse does not have an SSN, explain why in Section IX, Item 25, Remarks)

11D. DATE OF MARRIAGE

 

MONTH

DAY

YEAR

11E. PLACE OF MARRIAGE (City and State, County and State, or City and Country) City or County

State/Province

Country

11F. HOW WERE YOU MARRIED? (Check one)

CIVIL CEREMONY (i.e. Justice of the Peace)

RELIGIOUS CEREMONY (i.e. Minister, Priest, Rabbi, etc.)

 

 

 

 

 

 

 

 

 

TRIBAL

PROXY

COMMON LAW

OTHER (Explain)

 

 

 

 

 

12A. IS YOUR SPOUSE ALSO A VETERAN?

 

 

 

 

 

 

 

 

 

12B. SPOUSE'S VA FILE NUMBER (If applicable)

12C. SPOUSE'S SERVICE NUMBER (If applicable)

 

 

YES

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If you are a veteran that VA is paying additional benefits for a stepchild and you no longer live with the stepchild's biological or adoptive parent, complete Section V.

13A. DO YOU LIVE TOGETHER?

 

13B. REASON FOR SEPARATION (For example, marital problems, job requirements, health, etc.)

 

YES

NO (If "NO," complete Items 13B and 13C)

 

 

 

 

 

 

 

 

 

 

 

13C. CURRENT MAILING ADDRESS OF SPOUSE (Number and Street or Rural Route, P.O. Box, City, State, ZIP Code and Country)

 

 

 

 

 

 

 

No. &

 

 

 

 

 

Street

 

 

 

 

 

Apt./Unit Number

 

City

 

 

 

 

 

State/Province

 

Country

 

ZIP Code/Postal Code

 

VA FORM

 

 

 

 

 

 

21-686c

 

 

SUPERSEDES VA FORM 21-686c, JUN 2017.

SEP 2018

 

 

 

 

 

 

 

Page 7

VETERAN'S SOCIAL SECURITY NO.

NOTE: You must provide complete information about your prior marriages and your current spouse's prior marriages.

14.VETERAN/CLAIMANT'S PREVIOUS MARITAL INFORMATION (If no prior marriages, this section may be left blank)

14A. (1) TO WHOM MARRIED (First, Middle Initial, Last Name)

14A. (2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

City or County

State/Province

Country

14A. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

14A. (4) DATE AND PLACE MARRIAGE TERMINATED

(MM-DD-YYYY)

City or County

State/Province

Country

14B. (1) TO WHOM MARRIED (First, Middle Initial, Last Name)

14B. (2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

City or County

State/Province

Country

14B. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

14B. (4) DATE AND PLACE MARRIAGE TERMINATED

(MM-DD-YYYY)

City or County

State/Province

Country

14C. (1) TO WHOM MARRIED (First, Middle Initial, Last Name)

14C. (2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

 

 

 

 

City or County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

Country

14C. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

14C. (4) DATE AND PLACE MARRIAGE TERMINATED

(MM-DD-YYYY)

City or County

State/Province

Country

14D. (1) TO WHOM MARRIED (First, Middle Initial, Last Name)

14D. (2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

 

 

 

 

 

 

 

 

City or County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

Country

14D. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

14D. (4) DATE AND PLACE MARRIAGE TERMINATED

(MM-DD-YYYY)

City or County

VA FORM 21-686c, SEP 2018

State/Province

 

Country

 

 

 

Page 8

VETERAN'S SOCIAL SECURITY NO.

15.CURRENT SPOUSE'S PREVIOUS MARITAL INFORMATION (If no prior marriages, this section may be left blank)

15A. (1) TO WHOM MARRIED (First, Middle Initial, Last Name)

15A. (2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

City or County

State/Province

Country

15A. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

15A. (4) DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)

City or County

State/Province

Country

15B. (1) TO WHOM MARRIED (First, Middle Initial, Last Name)

15B. (2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

City or County

State/Province

Country

15B. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

15B. (4) DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)

City or County

State/Province

Country

15C.

(1) TO WHOM MARRIED (First, Middle Initial, Last Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15C.

(2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City or County

State/Province

Country

15C. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

15C. (4) DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)

City or County

State/Province

Country

15D.

(1) TO WHOM MARRIED (First, Middle Initial, Last Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15D.

(2) DATE AND PLACE OF MARRIAGE

(MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City or County

State/Province

Country

15D. (3) REASON FOR TERMINATION

Death

Divorce

Annulment

Other (Explain):

15D. (4) DATE AND PLACE MARRIAGE TERMINATED (MM-DD-YYYY)

City or County

VA FORM 21-686c, SEP 2018

State/Province

 

Country

 

 

 

Page 9

VETERAN'S SOCIAL SECURITY NO.

SECTION III: INFORMATION NEEDED TO ADD CHILD(REN)

(If claiming more than four children, fill out addendum (Page 15) and submit with application)

16A. NAME OF FIRST CHILD TO ADD (First, Middle Initial, Last)

16B. SOCIAL SECURITY NUMBER

16C. DATE OF BIRTH (MM-DD-YYYY)

16D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)

City or County State/Province Country

16E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

16F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES

No. &

Street

 

Apt./Unit Number

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

Country

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16G. CHILD STATUS (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIOLOGICAL

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

ADOPTED

CHILD INCAPABLE OF SELF-SUPPORT

 

CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 16H)

STEPCHILD (If checked, complete Item 16I)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16H. HOW AND WHEN MARRIAGE ENDED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

DIVORCE

 

OTHER (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNULLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16I. IF YOU CHECKED "STEPCHILD" IN ITEM 16G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?

 

 

 

 

 

 

 

 

 

YES (If "Yes," provide the date the child entered veteran's household) DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17A. NAME OF SECOND CHILD TO ADD (First, Middle Initial, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17B. SOCIAL SECURITY NUMBER

17C. DATE OF BIRTH (MM-DD-YYYY)

17D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)

City or County State/Province Country

17E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

17F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES No. &

Street

 

Apt./Unit Number

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

 

Country

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17G. CHILD STATUS (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIOLOGICAL

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

ADOPTED

CHILD INCAPABLE OF SELF-SUPPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 17H)

STEPCHILD (If checked, complete Item 17I)

 

17H. HOW AND WHEN MARRIAGE ENDED

 

 

DIVORCE

 

 

OTHER (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNULLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17I. IF YOU CHECKED "STEPCHILD" IN ITEM 17G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?

 

 

 

 

 

 

 

 

YES (If "Yes," provide the date the child entered veteran's household) DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 21-686c, SEP 2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 10

VETERAN'S SOCIAL SECURITY NO.

SECTION III: INFORMATION NEEDED TO ADD CHILD(REN) (Continued)

(If claiming more than four children, fill out addendum (Page 15) and submit with application)

18A. NAME OF THIRD CHILD TO ADD (First, Middle Initial, Last)

18B. SOCIAL SECURITY NUMBER

18C. DATE OF BIRTH (MM-DD-YYYY)

18D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)

City or County State/Province Country

18E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

18F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES

No. &

Street

 

Apt./Unit Number

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

Country

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18G. CHILD STATUS (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIOLOGICAL

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

ADOPTED

CHILD INCAPABLE OF SELF-SUPPORT

 

CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 18H)

STEPCHILD (If checked, complete Item 18I)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18H. HOW AND WHEN MARRIAGE ENDED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

DIVORCE

 

OTHER (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNULLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18I. IF YOU CHECKED "STEPCHILD" IN ITEM 18G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?

 

 

 

 

 

 

 

 

 

YES (If "Yes," provide the date the child entered veteran's household) DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19A. NAME OF FOURTH CHILD TO ADD (First, Middle Initial, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19B. SOCIAL SECURITY NUMBER

19C. DATE OF BIRTH (MM-DD-YYYY)

19D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)

City or County State/Province Country

19E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

19F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES No. &

Street

 

Apt./Unit Number

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

 

Country

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19G. CHILD STATUS (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIOLOGICAL

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

ADOPTED

CHILD INCAPABLE OF SELF-SUPPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 19H)

STEPCHILD (If checked, complete Item 19I)

 

19H. HOW AND WHEN MARRIAGE ENDED

 

 

DIVORCE

 

 

OTHER (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNULLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19I. IF YOU CHECKED "STEPCHILD" IN ITEM 19G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?

 

 

 

 

 

 

 

 

YES (If "Yes," provide the date the child entered veteran's household) DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 21-686c, SEP 2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 11

VETERAN'S SOCIAL SECURITY NO.

SECTION IV: VETERAN REPORTING DIVORCE FROM FORMER SPOUSE (If you have stepchild(ren), also complete Section V)

NOTE: If marriage ended as an annulment or declared void, use Section IX, Item 25, "Remarks" to explain.

20A. NAME OF FORMER SPOUSE (First, Middle Initial, Last)

20B. PLACE OF DIVORCE (Provide city and state, county and state, or city and country)

 

 

 

 

 

 

City or County

 

State/Province

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20C. DATE OF DIVORCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION V: VETERAN/CLAIMANT REPORTING ON STEPCHILD(REN)

21A. (1) DID YOU HAVE A STEPCHILD(REN) THAT WAS THE BIOLOGICAL OR ADOPTED CHILD(REN) OF THE FORMER SPOUSE LISTED IN ITEM 20A?

YES (If "YES," list the name(s) of the stepchild(ren) here):

NO (If "NO," skip to Section VI)

21A. (2) NAME(S) OF STEPCHILD(REN) (First, Middle Initial, Last)

21B. ARE YOU STILL SUPPORTING YOUR STEPCHILD(REN) LISTED IN ITEM 21A?

YES (If "YES," complete Items 21C through 21L)

NO (If "NO," skip to Section VI)

21C. NAME OF STEPCHILD YOU ARE SUPPORTING

21D. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE THE NAME OF PERSON WITH WHOM STEPCHILD RESIDES

21E. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE A COMPLETE ADDRESS

No. &

Street

 

Apt./Unit Number

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

Country

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21F. DATE STEPCHILD LEFT VETERAN'S HOUSEHOLD (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21G. FINANCIAL SUPPORT PROVIDED

 

 

 

 

More than half

 

Half

 

 

 

Less than half

21H. NAME OF STEPCHILD YOU ARE SUPPORTING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21I. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE THE NAME OF PERSON WITH WHOM STEPCHILD RESIDES

21J. IF STEPCHILD DOES NOT LIVE WITH YOU, PROVIDE A COMPLETE ADDRESS

No. &

Street

Apt./Unit Number

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21K. DATE STEPCHILD LEFT VETERAN'S HOUSEHOLD (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21L. FINANCIAL SUPPORT PROVIDED

 

 

More than half

 

 

Half

Less than half

VA FORM 21-686c, SEP 2018

Page 12

 

VETERAN'S SOCIAL SECURITY NO.

SECTION VI: VETERAN/CLAIMANT REPORTING DEATH OF A DEPENDENT

22A. (1) DEPENDENT TYPE (Check all that apply)

 

 

 

 

SPOUSE

MINOR CHILD (UNDER 18 YEARS OLD

STEPCHILD

ADOPTED

DEPENDENT PARENT

CHILD INCAPABLE OF SELF-SUPPORT

18-23 YEARS OLD AND IN SCHOOL

 

 

22B. NAME OF DEPENDENT(First, Middle Initial, Last)

22C. DATE OF DEATH (MM/DD/YYYY)

22D. PLACE OF DEATH (City & State, County & State, or City & Country)

City or County

22A. (2) DEPENDENT TYPE (Check all that apply)

State/Province

Country

SPOUSE

MINOR CHILD (UNDER 18 YEARS OLD

STEPCHILD

ADOPTED

DEPENDENT PARENT

CHILD INCAPABLE OF SELF-SUPPORT

18-23 YEARS OLD AND IN SCHOOL

 

 

22B. NAME OF DEPENDENT (First, Middle Initial, Last)

22C. DATE OF DEATH (MM/DD/YYYY)

22D. PLACE OF DEATH (City & State, County & State, or City & Country)

City or County

State/Province

Country

SECTION VII: VETERAN/CLAIMANT REPORTING MARRIAGE OF CHILD

23A. NAME OF CHILD (First, Middle Initial, Last)

23B. DATE OF MARRIAGE (MM-DD-YYYY)

SECTION VIII: VETERAN/CLAIMANT REPORTING A SCHOOLCHILD OVER 18 HAS STOPPED ATTENDING SCHOOL

24A. NAME OF SCHOOLCHILD (First, Middle Initial, Last)

24B. DATE SCHOOLCHILD STOPPED ATTENDING SCHOOL (MM-DD-YYYY)

VA FORM 21-686c, SEP 2018

Page 13

VETERAN'S SOCIAL SECURITY NO.

SECTION IX: REMARKS

25. REMARKS (If any)

SECTION X: BENEFICIARY/CLAIMANT'S CERTIFICATION AND SIGNATURE (Note: Completion of this section is REQUIRED to process your request)

IMPORTANT: The primary purpose of this form is to gather information or statements that may result in a change to your VA benefits. By signing this form you have given permission to make benefit payment changes that could result in the creation of an overpayment. If such adverse actions are taken you will receive additional notification from VA regarding repayment options.

I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge and belief.

26A. SIGNATURE OF BENEFICIARY/CLAIMANT OR ALTERNATE SIGNER* (REQUIRED)

(FOR USE BY VA ONLY)

26B. DATE (MM/DD/YYYY)

*ALTERNATE SIGNER: By signing on behalf of the beneficiary/claimant, I certify that the claimant is:

•under the age of 18,

•mentally incompetent to provide substantially accurate information needed to complete the form or to certify that the statements made on the form are true and complete, or

•physically unable to sign the form

*ALTERNATE SIGNER: By signing on behalf of the beneficiary/claimant, I certify that I am:

•a court-appointed representative,

•an attorney in fact or agent authorized to act on behalf of the claimant under a durable power of attorney,

•a person who is responsible for the care of the claimant, to include but not limited to a spouse or other relative, or

•a manager or principal officer acting on behalf of an institution which is responsible for the care of the claimant.

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, or for the fraudulent acceptance of any payment to which you are not entitled.

PRIVACY ACT INFORMATION: 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 required to obtain or retain benefits. Giving us your and your dependents' SSN account information is mandatory. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 USC 5101 (c)(1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.

RESPONDENT BURDEN: We need this information to determine marital status and eligibility for an additional allowance for dependents under 38 U.S.C. 1115. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 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 www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-686c, SEP 2018

Page 14

VETERAN'S SOCIAL SECURITY NO.

SECTION XI: ADDITIONAL CHILD(REN) (Addendum)

(Please submit this page with the completed application if you have additional children to add to your claim. If more space is

needed, please make additional copies of this page to submit with your application.)

1A. NAME OF ADDITIONAL CHILD TO ADD (First, Middle Initial, Last)

1B. SOCIAL SECURITY NUMBER

1C. DATE OF BIRTH (MM-DD-YYYY)

1D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)

City or County State/Province Country

1E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

1F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES No. &

Street

 

 

Apt./Unit Number

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1G. CHILD STATUS (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIOLOGICAL

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

 

 

ADOPTED

 

 

CHILD INCAPABLE OF SELF-SUPPORT

 

 

CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 1H)

 

 

STEPCHILD (If checked, complete Item 1I)

 

 

1H. HOW AND WHEN MARRIAGE ENDED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

DIVORCED

 

 

OTHER (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNULLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1I. IF YOU CHECKED "STEPCHILD" IN ITEM 1G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?

 

 

 

 

 

 

 

 

 

 

YES (If "Yes," provide the date the child entered veteran's household)

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2A. NAME OF ADDITIONAL CHILD TO ADD (First, Middle Initial, Last)

2B. SOCIAL SECURITY NUMBER

2C. DATE OF BIRTH (MM-DD-YYYY)

2D. PLACE OF BIRTH (Provide City and State, County and State, or City and Country)

City or County State/Province

2E. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT PROVIDE NAME OF PERSON THE CHILD RESIDES WITH

Country

2F. IF THE CHILD DOES NOT LIVE WITH THE CLAIMANT, PROVIDE COMPLETE PHYSICAL ADDRESS WHERE CHILD RESIDES No. &

Street

 

Apt./Unit Number

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State/Province

 

 

 

 

Country

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2G. CHILD STATUS (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIOLOGICAL

18-23 YEARS OLD AND IN SCHOOL (If checked, fill out VA Form 21-674)

 

 

ADOPTED

CHILD INCAPABLE OF SELF-SUPPORT

 

CHILD PREVIOUSLY MARRIED (If checked, provide the date marriage ended and how the marriage ended in Item 2H)

STEPCHILD (If checked, complete Item 2I)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2H. HOW AND WHEN MARRIAGE ENDED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

DIVORCED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNULLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2I. IF YOU CHECKED "STEPCHILD" IN ITEM 2G, IS STEPCHILD THE BIOLOGICAL CHILD OF YOUR SPOUSE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE (MM-DD-YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES (If "Yes," provide the date the child entered veteran's household)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 21-686c, SEP 2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAGE 15 - Addendum

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