VA Form 21P-4171 at a glance
What it is: VA Form 21P-4171 is the Supporting Statement Regarding Marriage.
Where and when to file: Mail to: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365
Who signs: The PERSON COMPLETING THIS FORM signs in ink in Box 18A, and in 18B enters the date signed (MM/DD/YYYY).
The NAME OF PERSON COMPLETING THIS FORM is in Box 4A, and that person understands that this statement will be considered in connection with an application for VA benefits based on a marital relationship between the veteran and the person named in Item 3.
A filled-in VA Form 21P-4171 example: a friend completes the statement
How to fill out VA Form 21P-4171, box by box
Boxes 1 to 3, veteran and claimed spouse
In Box 1, enter the VETERAN/BENEFICIARY'S NAME (First, Middle Initial, Last).
Enter the VETERAN'S SOCIAL SECURITY NUMBER in 2A and the VA FILE NUMBER (If applicable) in 2B.
In Box 3, enter the CLAIMED SPOUSE OR SURVIVING SPOUSE'S NAME (First, Middle Initial, Last).
Boxes 4A and 4B, person completing this form
In Box 4A, enter the NAME OF PERSON COMPLETING THIS FORM (First, Middle Initial, Last).
In Box 4B, enter the ADDRESS OF PERSON COMPLETING THIS FORM (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country).
Boxes 5A to 7D, relationship, how long and how often
In Box 5A, enter your relationship to the veteran (Parent, child, brother, sister, etc.). If not related, state "None".
In Box 5B, enter your relationship to the claimed spouse (Parent, child, brother, sister, etc.). If not related, state "None".
In Box 6A, enter how long you have known the veteran, and in 6B how long you have known the claimed spouse (Months, years).
In Box 7A, enter how often you have visited the veteran, and in 7B on what occasions.
In Box 7C, enter how often you have visited the claimed spouse, and in 7D on what occasions you have met the claimed spouse.
Boxes 8 to 10B, generally known as married
Box 8: Were the veteran and the claimed spouse generally known as married? Check YES or NO.
Box 9: Did either the veteran or claimed spouse ever deny the marriage? Check YES or NO.
Box 10A: Did you consider the veteran and the claimed spouse to be married? Check YES or NO. If "Yes," complete 10B.
In Box 10B, provide facts and reasons for such belief. If additional space needed use Item 17, "Remarks".
Boxes 11 to 12C, name known by and married to one another
In Box 11, write the first name and last name by which the spouse was known.
Box 12A: Had you ever heard the veteran or the claimed spouse refer to each other as married to one another? Check YES or NO. If "Yes," complete 12B and 12C.
In Box 12B, enter the date (MM/DD/YYYY), and in 12C the place.
Boxes 13A to 14B, live together
Box 13A: Did the veteran and the claimed spouse maintain a home and live together as married to one another? Check YES or NO. If "Yes," complete 13B.
In Box 13B, list the periods of time and places where the veteran and the claimed spouse had lived together: BEGINNING DATE (MM/DD/YYYY), ENDING DATE (MM/DD/YYYY), city or town and state.
Box 14A: Had the veteran and the claimed spouse lived together continuously? Check YES or NO. If "Yes," complete 14B, the explanation.
Boxes 15A to 16B, other marriages
Box 15A: Had the veteran ever entered into any other marriage(s)? Check YES or NO. If "Yes," complete 15B.
In Box 15B, for each of the OTHER MARRIAGES OF VETERAN, enter to whom married, type of marriage (Ceremonial, etc.), date (MM/DD/YYYY) and place of marriage, how marriage ended (Death, divorce, etc.), and date (MM/DD/YYYY) and place marriage ended.
Box 16A: Has the claimed spouse ever entered into any other marriage(s)? Check YES or NO. If "Yes," complete 16B.
In Box 16B, for each of the OTHER MARRIAGES OF CLAIMED SPOUSE, enter type of marriage (Ceremonial, etc.), to whom married, date (MM/DD/YYYY) and place of marriage, how marriage ended (Death, divorce, etc.), and date (MM/DD/YYYY) and place marriage ended.
Boxes 17 to 20B, remarks, signature and witnesses
In Box 17, write any remarks.
Certify that the statements are true and correct to the best of your knowledge and belief.
The PERSON COMPLETING THIS FORM signs in ink in Box 18A, and in 18B enters the date signed (MM/DD/YYYY).
In Box 18C, enter the DAYTIME TELEPHONE NUMBER, and in 18D the EVENING TELEPHONE NUMBER (Including Area Code).
A signature by "X" mark must be witnessed by two persons to whom the signer is personally known, and the signature and addresses of the witnesses must be entered.
Witnesses sign in ink in Boxes 19A and 20A and enter their addresses in 19B and 20B.
More rules for VA Form 21P-4171
Please complete all items. Your answer to every question is important to help complete the claimant's claim. If you do not know the answer, write "unknown." For additional space, use Item 17, "Remarks," or attach a separate sheet, indicating the item number to which the answers apply. See page 2 for mailing information.
Common questions about VA Form 21P-4171
Where do I file it?
Mail to: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365
Are there fees?
Fees for claims: Generally, a VA-accredited attorney or agent may charge a fee for assisting in seeking further review of a claim for VA benefits only after VA has issued an initial decision on the claim and the attorney or agent has complied with the applicable power-of-attorney and the fee agreement requirements.
Is there a penalty?
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 21P-4171 (MAY 2024), Supporting Statement Regarding Marriage, Department of Veterans Affairs (the Official source link on this page).