VA Form 21-4170 at a glance
What it is: The Statement of Marital Relationship provides information to VA to determine marital status. Call 1-800-827-1000; if you use a Telecommunications Device for the Deaf, relay number is 711. Pages 4 and 5.
Where and when to file: Documents may be submitted by mail, in person at a VA regional office or electronically. However, VA recommends submitting correspondence electronically as this is the fastest method of receipt. To learn more about how to submit documents and claims electronically, visit www.va.gov/disability/upload-supporting-evidence. You can also go directly to access.va.gov to digitally upload any correspondence using Direct Upload. If you need assistance, you can find a local, accredited representative at https://www.benefits.va.gov/vso/.
This form is to be completed by the veteran (if living) and the person who is claiming to be the spouse or surviving spouse of the veteran. Note: For the purposes of this form, the person who is claiming to be the spouse or surviving spouse of the veteran is referred to as such. If you do not know the answer, write "unknown". Submit any documents that show your marital status as holding yourselves out as married or whether you are generally accepted as such in the community in which you live or lived. For example, lease agreements, joint bank statements, utility bills, tax returns, insurance forms, employment records, and any other documents showing marital status. Be advised that original documents will not be returned to you. VA highly encourages you to submit certified copies instead. If additional space is needed, use Section VI: Remarks, indicating the item number to which the answers apply.
A filled-in VA Form 21-4170 example: a married couple fills out page 1
How to fill out VA Form 21-4170, box by box
Section I, the veteran's identification information
In Section I, enter the veteran's name (First, Middle Initial, Last), Social Security Number, VA File Number (If applicable), Date of Birth (MM/DD/YYYY), Service Number (If applicable) and Telephone Number (Include Area Code), and the International Phone Number (If applicable).
Section II, the spouse or surviving spouse
In Section II, enter the name of the spouse or surviving spouse (First, Middle Initial, Last), the Social Security Number of the spouse or surviving spouse and the Date of Birth of the spouse or surviving spouse (MM/DD/YYYY).
Box 10, the mailing address
In Box 10, enter the mailing address of the veteran or claimant: number and street or rural route, P.O. Box, City, State, ZIP Code and Country.
Section III, the marital relationship claimed
In Section III, enter the date you began living as marital partners (MM/DD/YYYY) in 11A, the name(s) you were known by before you began living as marital partners (First, Middle Initial, Last) in 11B, and the place you began living as marital partners (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country; No. & Street) in 11C.
Items 11D to 11F, last name, relationship and living together
Items 11D through 13 are to be completed by the spouse or surviving spouse.
11D. After you began living with the veteran, did you use his/her last name? ALWAYS, SOMETIMES or NEVER. 11E. What did you agree your relationship would be at the time you began living together? (Explain)
11F. Have (had) you lived together continuously from that time until this date (or the veteran's death)? If YES, skip to Item 13. If NO, complete Item 12.
12, periods of separation
12. List all periods of separation: the beginning date (MM/DD/YYYY), the ending date (MM/DD/YYYY) and the reason for separation.
13, periods of time and places where you lived as marital partners
13. List all periods of time and places where you lived as marital partners: the beginning date (MM/DD/YYYY), the ending date (MM/DD/YYYY) and the address (Street address, city, and state).
Section IV, your children
Item 14A: Have you had children together? If YES, complete Item 14B; if NO, skip to Item 15A. Send a certified copy of the public record of birth for each child listed in Item 14B. 14B. Full name of child (First, Middle Initial, Last). 14C. Place of birth (City/State or Country).
Section V, your marital history
Furnish complete information about all marriages of the veteran and spouse or surviving spouse. If you need additional space, use Section VI: Remarks. Attach copies of divorce decrees. Item 15A: Have (had) the veteran ever lived with another person as a marital partner? If YES, complete Item 15B through 15M; if NO, skip to Item 16A. 15B and 15H. Date of marriage (MM/DD/YYYY). 15C and 15I. Place (City/State or Country). 15D and 15J. To whom married (First, Middle Initial, Last). 15E and 15K. Date marriage ended (MM/DD/YYYY). 15F and 15L. Place (City/State or Country). 15G and 15M. How marriage ended (Death, divorce, etc.).
Item 16A: Has the spouse or surviving spouse ever lived with another person as a marital partner? If YES, complete Item 16B through 16M; if NO, skip to Item 17.
Sections VII and VIII, signatures and witnesses
In Section VII, the veteran signs in 18A (REQUIRED) and enters the date signed in 18B (MM/DD/YYYY). The claimed spouse or surviving spouse signs in 19A (REQUIRED) and enters the date signed in 19B (MM/DD/YYYY). The statements in this document are true and correct to the best of your knowledge and belief.
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 in 20A, 20B, 21A and 21B.
More rules for VA Form 21-4170
You may fill out the form online or by hand. If completed by hand, print the information neatly and legibly, insert one letter per box, and completely fill in each applicable check box to help expedite processing of the form.
Section VI is REMARKS. 17. REMARKS (If any).
Common questions about VA Form 21-4170
Where do I file it?
If you prefer to mail your correspondence, please use the related mailing address. Compensation claims: Department of Veterans Affairs Evidence Intake Center, PO Box 4444, Janesville, WI 53547-4444. Pension & survivors benefit claims: Department of Veterans Affairs Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365. Fiduciary: Department of Veterans Affairs Fiduciary Intake, PO Box 95211, Lakeland, FL 33804-5211. Board of Veterans' Appeals: Department of Veterans Affairs Board of Veterans' Appeals, PO Box 27063, Washington, DC 20038. These addresses serve all United States and foreign locations.
Is there a 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.
Sources
[1] VA Form 21-4170 (AUG 2024), Statement of Marital Relationship, Department of Veterans Affairs (the Official source link on this page).