Va Form 21 4170 PDF Details

The VA Form 21-4170, known as the Statement of Marital Relationship, stands as a critical document within the United States Department of Veterans Affairs' array of forms, primarily serving spouses or surviving spouses of veterans. This form meticulously collects information to ascertain eligibility for additional benefits, thereby playing a significant role in the administration of various veterans' benefits, including pensions and dependency and indemnity compensation. Its detailed structure requires applicants to provide comprehensive personal and relationship information, including the history of the marital relationship, any children shared, and previous marital histories of both the veteran and the spouse or surviving spouse. The form operates under a strict privacy framework, adhering to the Privacy Act of 1974, ensuring that the information collected remains confidential, with disclosure only permissible under authorized circumstances. Applicants are reminded of the importance of accuracy, with the VA emphasizing the potential legal repercussions of willful misinformation. Navigating through the VA Form 21-4170, individuals are guided to submit relevant supportive documents to reinforce their claim, highlighting the critical synergy between authentic representation of one’s marital status and the successful acquisition of deserved benefits.

QuestionAnswer
Form NameVa Form 21 4170
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva form 21 4170, va form 21 4170 fillable, 13G, don't use va form 21 4138

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OMB Control No. 2900-0114 Respondent Burden: 25 Mins.

STATEMENT OF

MARITAL RELATIONSHIP

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, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). 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.

VA DATE STAMP (DO NOT WRITE IN THIS SPACE)

RESPONDENT BURDEN: We need this information to determine eligibility for additional benefits as a spouse of a veteran or eligibility for pension or dependency and indemnity compensation as the surviving spouse of a veteran (38 U.S.C. 101, 103, and 1102). We estimate that you will need an average of 25 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.

INSTRUCTIONS: This form is to be completed by the veteran (if living) and the person who is claiming to be the spouse or surviving spouse. Note: For the purposes of this form, the person who is claiming to be the spouse or surviving spouse is referred to as "spouse or surviving spouse." Print all answers clearly. Your answer to every question is important to help us complete your claim. If you do not know the answer, write "unknown." For additional space, use Item 14, "Remarks, " or attach a separate sheet, indicating the item number to which the answers apply.

IMPORTANT INFORMATION: Submit any documents that show the veteran and the spouse or surviving spouse as husband and wife; for example, lease agreements, joint bank statements, utility bills, tax returns, insurance forms, employment records, and any other documents showing marital status. Original documents will be returned to you.

SECTION I - INFORMATION ABOUT THE VETERAN AND THE SPOUSE OR SURVIVING SPOUSE

1. NAME OF VETERAN (First, middle, last)

2.VA FILE NUMBER

C/SS -

3. NAME OF SPOUSE OR SURVIVING SPOUSE (First, middle, last)

4.SOCIAL SECURITY NUMBER OF SPOUSE OR SURVIVING SPOUSE

5.DATE OF BIRTH OF SPOUSE OR SURVIVING SPOUSE (Month, day, year)

6.COMPLETE ADDRESS OF VETERAN OR CLAIMANT (Number and street or rural route, city or P. O., State and ZIP Code)

SECTION II - INFORMATION ABOUT THE CLAIMED MARITAL RELATIONSHIP

7A. DATE YOU BEGAN LIVING AS HUSBAND AND WIFE (Month, day, year)

7B. PLACE YOU BEGAN LIVING AS HUSBAND AND WIFE (Include number and street or rural route, city or P. O., State and ZIP Code)

7C. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS HUSBAND AND WIFE (First, middle, last)

7D. TO BE COMPLETED BY THE SPOUSE OR SURVIVING SPOUSE:

AFTER YOU BEGAN LIVING WITH THE VETERAN, DID YOU USE HIS/HER LAST NAME?

ALWAYS

SOMETIMES

NEVER

8.WHAT DID YOU AGREE YOUR RELATIONSHIP WOULD BE AT THE TIME YOU BEGAN LIVING TOGETHER?

9A. HAVE (HAD) YOU LIVED TOGETHER CONTINUOUSLY FROM THAT TIME UNTIL THIS DATE (OR THE VETERAN'S DEATH)?

 

 

YES

NO (If "Yes," go to Item 10. If "No," complete Item 9B)

 

 

 

 

 

 

 

9B. LIST ALL PERIODS OF SEPARATION

BEGINNING DATE

(Month, day, year)

ENDING DATE

(Month, day, year)

REASON FOR SEPARATION

 

10. LIST ALL PERIODS OF TIME AND PLACES WHERE YOU LIVED AS HUSBAND AND WIFE

BEGINNING DATE

ENDING DATE

ADDRESS (Street address, city, and State)

(Month, day, year)

(Month, day, year)

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM

21-4170

EXISTING STOCKS OF VA FORM 21-4170, OCT 2004,

JUL 2011

WILL BE USED.

SECTION III - INFORMATION ABOUT YOUR CHILDREN

IMPORTANT INFORMATION: Send a certified copy of the public record of birth for each child listed in Item 11B.

11A. HAVE YOU HAD CHILDREN TOGETHER?

 

YES

NO (If "Yes," complete Item 11B. If "No," go to Item 12A.)

 

 

 

 

 

11B. FULL NAME OF CHILD (First, middle, last)

11C. PLACE OF BIRTH (City/State or Country)

 

 

 

 

 

 

 

 

 

SECTION IV - INFORMATION ABOUT YOUR MARITAL HISTORY

INSTRUCTIONS: Furnish complete information about all marriages of the veteran and spouse or surviving spouse. If you need additional space, please attach a separate sheet of paper providing the requested information about the marriages.

IMPORTANT INFORMATION: Attach a copy of divorce decrees.

12A. HAS (HAD) THE VETERAN EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?

YES

NO

(If "Yes," complete Items 12B through 12G. If "No," go to Item 13A.)

12B. DATE OF

MARRIAGE

(Month, day, year)

12C. PLACE

(City/State or country)

12D. TO WHOM MARRIED

(First name, middle initial, last name)

12E. DATE MARRIAGE ENDED

(Month, day,

year)

12F. PLACE

(City/State or country)

12G. HOW MARRIAGE ENDED

(Death, divorce, etc.)

13A. HAS THE SPOUSE OR SURVIVING SPOUSE EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?

 

YES

NO

(If "Yes," complete Item 13B through 13G. If "No," go to Item 14.)

 

 

 

 

 

 

 

 

 

 

 

13B. DATE OF

 

 

 

13D. TO WHOM MARRIED

13E. DATE

 

13G. HOW

 

 

13C. PLACE

MARRIAGE

13F. PLACE

MARRIAGE

MARRIAGE

 

 

 

 

(First name, middle initial, last

ENDED

ENDED

(Month, day,

 

 

(City/State or country)

(City/State or country)

 

 

name)

(Month, day,

(Death,

year)

 

 

 

 

 

 

 

 

year)

 

divorce, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. REMARKS

SECTION V - CERTIFICATION, SIGNATURE(S), AND WITNESSES

I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge and belief.

15A. SIGNATURE OF VETERAN

15B. DATE SIGNED

16A. SIGNATURE OF CLAIMED SPOUSE OR SURVIVING SPOUSE

16B. DATE SIGNED

WITNESSES TO SIGNATURES IF MADE BY "X" MARK

NOTE: Signature by mark must be witnessed by two persons to whom the veteran or the claimed spouse or surviving spouse is personally known and the signatures and addresses of the witnesses must be entered below.

17A. SIGNATURE OF WITNESS

17B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

18A. SIGNATURE OF WITNESS

18B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

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 21-4170, JUL 2011

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Step no. 1 of filling out don't use va form 21 4138

2. Just after completing the previous section, go on to the subsequent step and enter the essential details in these blanks - BEGINNING DATE Month day year, Month day year, ADDRESS Street address city and, VA FORM JUL, and EXISTING STOCKS OF VA FORM OCT.

BEGINNING DATE Month day year, EXISTING STOCKS OF VA FORM OCT, and Month day year inside don't use va form 21 4138

3. Completing A HAVE YOU HAD CHILDREN TOGETHER, YES, If Yes complete Item B If No go to, B FULL NAME OF CHILD First middle, C PLACE OF BIRTH CityState or, INSTRUCTIONS Furnish complete, SECTION IV INFORMATION ABOUT YOUR, IMPORTANT INFORMATION Attach a, A HAS HAD THE VETERAN EVER LIVED, YES, If Yes complete Items B through G, B DATE OF, MARRIAGE Month day, year, and C PLACE is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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