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.
Originals: original documents will not be returned to you; VA highly encourages certified copies instead.
Unknown answers: if you do not know the answer, write "unknown".
Items 11D through 13: to be completed by the spouse or surviving spouse.
Children: send a certified copy of the public record of birth for each child listed in Item 14B.
Divorce decrees: attach copies of divorce decrees.
Additional space: if additional space is needed, use Section VI: Remarks, indicating the item number to which the answers apply.
| Question | Answer |
|---|---|
| Form Name | VA Form 21-4170 |
| Form Length | 5 pages |
| Fillable? | Yes |
| Fillable fields | 228 |
| Avg. time to fill out | 38 min |
| Edition | AUG 2024 |
| Where to send | By mail, in person at a VA regional office or electronically |
| Who signs | The veteran and the claimed spouse or surviving spouse |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | VA Form 21-4170, 21-4170, VA 21-4170, VA Form 21 4170, 214170, Form 21-4170, Statement of Marital Relationship |
| Official source | VA Form 21-4170 (Rev AUG 2024), Department of Veterans Affairs |
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