Va Form 21 4171 PDF Details

The VA Form 21-4171, known as the Supporting Statement Regarding Marriage, serves a crucial role in the administration of benefits through the Department of Veterans Affairs (VA). It gathers essential information to substantiate a marital relationship between a claimant and a veteran, which directly impacts the determination and delivery of VA benefits. Imbued with strict confidentiality under the Privacy Act of 1974 and Title 38, Code of Federal Regulations 1.576, the form's sensitive data is shielded, ensuring privacy and security. The form requires detailed responses covering the history and dynamics of the claimed marital relationship, including the periods and places of cohabitation, any previous marriages, and the public acknowledgment of their union as husband and wife. Completing this form is voluntary, yet it is a necessary step for claimants to prove their eligibility for benefits based on their marital bond with a veteran. With a respondent burden of 20 minutes and a stringent warning against the submission of false statements, this form underlines the VA’s commitment to thorough verification and fair administration of veterans' benefits. Valid OMB control number displays and the option for public comment highlight the form’s compliance with federal standards for information collection, underscoring the importance of accuracy and governmental oversight in the process.

QuestionAnswer
Form NameVa Form 21 4171
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names12B, va form 21 4171, 13B, veteranlawblog org

Form Preview Example

OMB Control No. 2900-0115 Respondent Burden: 20 Minutes

SUPPORTING STATEMENT REGARDING MARRIAGE

Privacy Act Notice: 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, published in the Federal Register. Your obligation to respond is voluntary. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.

Respondent Burden: We need this information to determine eligibility for benefits based on a marital relationship between the claimant and the veteran (38 U.S.C. 101, 103, and 1102). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 20 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 and give your comments or ask for mailing information on where to send your comments.

VA DATE STAMP

(DO NOT WRITE IN THIS

SPACE)

INSTRUCTIONS: Please complete all items. Your answer to every question is important to help us 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.

1.FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN 2. FILE NUMBER

C/CSS-

3.FIRST NAME - MIDDLE NAME - LAST NAME OF CLAIMANT (SPOUSE OR SURVIVING SPOUSE)

4A. NAME OF PERSON COMPLETING THIS FORM

4B. ADDRESS OF PERSON COMPLETING THIS FORM

I understand 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.

5A. WHAT WAS/IS YOUR RELATIONSHIP

TO THE VETERAN? (Parent, child, brother, sister, etc. If not related, state "None")

5B. WHAT WAS / IS YOUR RELATIONSHIP TO THE CLAIMANT? (Parent, child,

brother, sister, etc. If not related, state"None")

6A. HOW LONG HAD/HAVE

YOU KNOWN THE

VETERAN? (Months,

years)

6B. HOW LONG HAD / HAVE

YOU KNOWN THE

CLAIMANT? (Months, years)

7A. HOW OFTEN HAD/HAVE YOU MET THE VETERAN?

7B. ON WHAT OCCASION(S) HAD/HAVE YOU MET THE VETERAN?

 

 

 

 

 

 

 

 

 

7C. HOW OFTEN HAVE YOU MET THE CLAIMANT?

7D. ON WHAT OCCASIONS HAVE YOU MET THE CLAIMANT?

 

 

 

 

 

 

 

 

 

8. WERE/ARE THE VETERAN AND THE CLAIMANT GENERALLY

9. DID/DO EITHER THE VETERAN OR CLAIMANT EVER DENY THE

 

KNOWN AS HUSBAND AND WIFE?

MARRIAGE?

 

 

 

YES

 

NO

 

 

 

 

NO

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10A. DID/DO YOU CONSIDER THE VETERAN AND THE CLAIMANT TO

10B. FACT AND REASONS FOR SUCH BELIEF "REMARKS" (If

 

BE HUSBAND AND WIFE?

 

necessary use section on reverse and key answers to item number)

 

 

 

 

NO (If "Yes," complete Item 10B)

 

 

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. NAME(S) BY WHICH CLAIMANT WAS/IS KNOWN

FIRST NAME

LAST NAME

12A. HAD/HAVE YOU EVER HEARD THE VETERAN OR THE CLAIMANT REFER TO EACH OTHER AS HUSBAND AND WIFE?

 

 

 

YES

 

NO (If "Yes," complete Items 12B and 12C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12B. DATE

12C. PLACE

 

 

 

 

 

 

 

13A. DID/DO THE VETERAN AND THE CLAIMANT MAINTAIN A HOME AND LIVE TOGETHER AS HUSBAND AND WIFE?

 

 

YES

 

NO (If "Yes," complete Item 13B)

 

 

 

 

 

 

 

 

13B. PERIODS OF TIME AND PLACES WHERE THE VETERAN AND THE CLAIMANT HAD/HAVE LIVED TOGETHER

BEGINNING DATE

ENDING DATE

CITY OR TOWN

STATE

VA FORM

21-4171

EXISTING STOCKS OF VA FORM 21-4171, NOV 2004,

JUN 2011

WILL BE USED.

14A. HAD/HAVE THE VETERAN AND THE CLAIMANT LIVED TOGETHER CONTINUOUSLY?

 

YES

 

NO (If "Yes," complete Item 14B)

14B. EXPLANATION

15A. HAD/HAS THE VETERAN EVER ENTERED INTO ANY OTHER MARRIAGE(S)?

 

YES

 

NO (If "Yes," complete Item 15B)

15B. OTHER MARRIAGES OF VETERAN

TO WHOM MARRIED

DATE AND PLACE

OF MARRIAGE

TYPE OF MARRIAGE

(Ceremonial, etc.)

HOW MARRIAGE

ENDED

(Death, divorce, etc.)

DATE AND PLACE MARRIAGE ENDED

16A. HAS THE CLAIMANT EVER ENTERED INTO ANY OTHER MARRIAGE(S)?

 

 

YES

 

NO (If "Yes," complete Item 16B)

 

 

 

 

 

 

 

 

 

16B. OTHER MARRIAGES OF CLAIMANT

TO WHOM MARRIED

DATE AND PLACE

OF MARRIAGE

TYPE OF MARRIAGE

(Ceremonial, etc.)

HOW MARRIAGE

ENDED

(Death, divorce, etc.)

DATE AND PLACE MARRIAGE ENDED

17. REMARKS

CERTIFICATION

 

 

 

 

 

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

 

 

18A. SIGNATURE

18B. DATE SIGNED

 

 

 

 

18C. DAYTIME TELEPHONE NUMBER (Including Area Code)

18D. EVENING TELEPHONE NUMBER (Including Area Code)

WITNESS TO SIGNATURE IF MADE BY "X" MARK

NOTE: Signature by 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 below.

19A. SIGNATURE OF WITNESS

19B. ADDRESS OF WITNESS

20A. SIGNATURE OF WITNESS

20B. ADDRESS OF WITNESS

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 21-4171, JUN 2011

How to Edit Va Form 21 4171 Online for Free

10B can be filled in online with ease. Simply use FormsPal PDF editing tool to get it done promptly. The tool is constantly improved by us, acquiring handy functions and turning out to be better. This is what you will want to do to begin:

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1. The 10B involves particular information to be inserted. Be sure that the next blanks are finalized:

Part no. 1 of filling out va form 21p 4171

2. The subsequent step would be to fill in the following blanks: A DIDDO YOU CONSIDER THE VETERAN, B FACT AND REASONS FOR SUCH BELIEF, YES, If Yes complete Item B, NAMES BY WHICH CLAIMANT WASIS, FIRST NAME, LAST NAME, A HADHAVE YOU EVER HEARD THE, YES, If Yes complete Items B and C, B DATE, C PLACE, A DIDDO THE VETERAN AND THE, YES, and If Yes complete Item B.

The right way to prepare va form 21p 4171 part 2

People often make errors while completing FIRST NAME in this part. Don't forget to revise everything you type in right here.

3. In this part, check out A HADHAVE THE VETERAN AND THE, YES, If Yes complete Item B, B EXPLANATION, A HADHAS THE VETERAN EVER ENTERED, YES, If Yes complete Item B, B OTHER MARRIAGES OF VETERAN, TO WHOM MARRIED, DATE AND PLACE, OF MARRIAGE, TYPE OF MARRIAGE, Ceremonial etc, HOW MARRIAGE, and ENDED. Each one of these need to be filled out with highest accuracy.

Step number 3 in submitting va form 21p 4171

4. To move onward, your next form section requires completing several fields. Included in these are TO WHOM MARRIED, DATE AND PLACE, OF MARRIAGE, TYPE OF MARRIAGE, Ceremonial etc, ENDED, Death divorce etc, DATE AND PLACE MARRIAGE ENDED, REMARKS, I CERTIFY THAT the foregoing, A SIGNATURE, B DATE SIGNED, and CERTIFICATION, which are key to continuing with this particular PDF.

How you can prepare va form 21p 4171 portion 4

5. The final step to submit this PDF form is integral. Make sure to fill out the required fields, and this includes C DAYTIME TELEPHONE NUMBER, D EVENING TELEPHONE NUMBER, WITNESS TO SIGNATURE IF MADE BY X, NOTE Signature by mark must be, A SIGNATURE OF WITNESS, B ADDRESS OF WITNESS, A SIGNATURE OF WITNESS, B ADDRESS OF WITNESS, PENALTY The law provides severe, and VA FORM JUN, prior to finalizing. Failing to accomplish that may produce a flawed and probably nonvalid paper!

WITNESS TO SIGNATURE IF MADE BY X, B ADDRESS OF WITNESS, and B ADDRESS OF WITNESS in va form 21p 4171

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