Va Form 21 0538 PDF Details

Navigating veteran affairs and staying informed about the benefits available can be a challenging task, yet it's essential for veterans and their families. Among the plethora of forms and documentations is the VA Form 21-0538, a crucial piece for veterans seeking to maintain their entitlement to additional allowances for dependents. The form serves as a mandatory verification process, ensuring the Department of Veterans Affairs (VA) has up-to-date information regarding the veteran's dependents, which directly impacts benefit allocations. Detailed instructions, a Privacy Act Notice, and information on the Respondent Burden are provided to guide applicants through the process, emphasizing the importance of accuracy and honesty in reporting changes in dependent status such as marriage, death, or adoption. The form not only facilitates the administrative process but also underscores the commitment of the VA to uphold the financial welfare of those who served and their families. Veterans are encouraged to utilize the resources provided, including the ability to contact VA for further assistance online or via toll-free numbers, underscoring the VA's efforts to streamline and support the submission process. The respondent burden is minimal, estimated at about 10 minutes, highlighting the VA's intent to make the verification process as efficient as possible while ensuring compliance with federal regulations and safeguarding the integrity of veteran benefits.

QuestionAnswer
Form NameVa Form 21 0538
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names 21-0538. STATUS OF DEPENDENTS QUESTIONNAIRE

Form Preview Example

OMB Approved No. 2900-0500

Respondent Burden: 10 Minutes

Expiration Date: 02/29/2024

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

MANDATORY VERIFICATION OF DEPENDENTS

INSTRUCTIONS: Before completing this form, read the Privacy Act and Respondent Burden on page 2. We use this form to determine continued eligibility to the additional allowance for dependents. For more information, 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 forms are available at www.va.gov/vaforms. After completing the form, mail to: Department of Veterans Affairs,

Evidence Intake Center, P.O. Box 4444, Janesville, WI, 53547-4444.

SECTION I: VETERAN'S IDENTIFICATION INFORMATION

NOTE: You may complete the form online or by hand. If completed by hand, print the information requested in ink, neatly and legibly, insert one letter per box, and completely fill in each applicable circle to help expedite processing of the form.

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

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER (If applicable)

4. DATE OF BIRTH (MM/DD/YYYY)

5. CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country)

No. &

Street

 

Apt./Unit Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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State/Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP Code/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.TELEPHONE NUMBER (Include Area Code)

 

 

 

 

 

 

 

 

 

 

7. E-MAIL ADDRESS

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter International Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II: STATUS CERTIFICATION

 

 

 

8. HAS THE STATUS OF YOUR DEPENDENT(S) CHANGED?

 

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

oIf "Yes," complete the section below that refers to the dependent(s) whose status has changed. o If "No," sign this form (Section V) and disregard the remaining sections of this form.

NOTE: If you have additional dependents not listed on the letter attached to this form, complete and submit VA Form 21-686c, Application Request to Add and/or Remove Dependents, and if claiming a child aged 18-23 years and in school, complete VA Form 21-674, Request for Approval of School Attendance. VA forms are available at www.va.gov/vaforms.

SECTION III: CHANGE IN SPOUSE STATUS

9. HOW DID STATUS CHANGE?

 

DATE ENDED (MM/DD/YYYY):

REASON MARRIAGE ENDED

 

 

MARRIAGE ENDED

 

Annulment

Divorce

Declared Void

DEATH

DATE OF DEATH (MM/DD/YYYY):

 

 

 

SECTION IV: CHANGE IN CHILD(REN)'S STATUS

NOTE: If your child has been adopted out of your family, input the date the adoption was finalized. If you have more than four children whose status has changed, use a separate VA Form 21-0538.

10A. CHILD'S NAME

 

10B. HOW STATUS CHANGED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARRIAGE OF CHILD

DATE OF MARRIAGE (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because of medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.

STEPCHILD IS NO LONGER A MEMBER OF HOUSEHOLD

LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):

VA FORM 21-0538, FEB 2021

SUPERSEDES VA FORM 21-0538, SEP 2020.

Page 1

VETERAN'S SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

SECTION IV: CHANGE IN CHILD(REN)'S STATUS (CONTINUED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11A. CHILD'S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11B. HOW STATUS CHANGED

 

 

 

DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARRIAGE OF CHILD

DATE OF MARRIAGE (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because of medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.

STEPCHILD IS NO LONGER A MEMBER OF HOUSEHOLD

LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):

12A. CHILD'S NAME

 

12B. HOW STATUS CHANGED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARRIAGE OF CHILD

DATE OF MARRIAGE (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because of medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.

LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):

STEPCHILD IS NO LONGER

A MEMBER OF HOUSEHOLD

13A. CHILD'S NAME

13B. HOW STATUS CHANGED

DEATH OF CHILD

DATE OF DEATH (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARRIAGE OF CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF MARRIAGE (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADOPTION OUT OF FAMILY

DATE OF ADOPTION (MM/DD/YYYY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Do not fill in the next circle if you live apart from the stepchild but are still providing at least half of the child's support or if you live apart from the stepchild because of medical reasons or because you or the child are incarcerated, attending school, or fulfilling a military service obligation.

STEPCHILD IS NO LONGER A MEMBER OF HOUSEHOLD

LAST DATE STEPCHILD WAS A MEMBER OF HOUSEHOLD (MM/DD/YYYY):

SECTION V: CERTIFICATION AND SIGNATURE

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

14A. SIGNATURE OF VETERAN (REQUIRED)

14B. DATE SIGNED (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 NOTICE: The 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 5, Code of Federal Regulations 1.526 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, Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. You must give us your and your dependents SSN account information. Applicants are required to provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C. 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 continued eligibility for an additional allowance for your spouse and/or child(ren). 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 10 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. Valid OMB control numbers can be located on the OMB Internet page at www.reginfo.gov/public/do/PRAMain If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-0538, FEB 2021

Page 2

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completing Va Form 21 0538 stage 1

Remember to fill up the NOTE If you have additional, SECTION III CHANGE IN SPOUSE STATUS, HOW DID STATUS CHANGE, DATE ENDED MMDDYYYY, REASON MARRIAGE ENDED, MARRIAGE ENDED, Annulment, Divorce, Declared Void, DEATH, DATE OF DEATH MMDDYYYY, SECTION IV CHANGE IN CHILDRENS, NOTE If your child has been, A CHILDS NAME, and DEATH OF CHILD space with the necessary information.

Completing Va Form 21 0538 stage 2

You can be requested for certain significant data if you need to fill up the VETERANS SOCIAL SECURITY NUMBER, A CHILDS NAME, SECTION IV CHANGE IN CHILDRENS, DEATH OF CHILD, DATE OF DEATH MMDDYYYY, MARRIAGE OF CHILD, DATE OF MARRIAGE MMDDYYYY, ADOPTION OUT OF FAMILY, DATE OF ADOPTION MMDDYYYY, B HOW STATUS CHANGED, NOTE Do not fill in the next, LAST DATE STEPCHILD WAS A MEMBER, STEPCHILD IS NO LONGER A MEMBER OF, A CHILDS NAME, and B HOW STATUS CHANGED area.

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The field A CHILDS NAME, B HOW STATUS CHANGED, DEATH OF CHILD, DATE OF DEATH MMDDYYYY, MARRIAGE OF CHILD, DATE OF MARRIAGE MMDDYYYY, ADOPTION OUT OF FAMILY, DATE OF ADOPTION MMDDYYYY, NOTE Do not fill in the next, LAST DATE STEPCHILD WAS A MEMBER, STEPCHILD IS NO LONGER A MEMBER OF, I HEREBY CERTIFY THAT the, SECTION V CERTIFICATION AND, A SIGNATURE OF VETERAN REQUIRED, and B DATE SIGNED MMDDYYYY should be where you add all sides' rights and responsibilities.

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