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.
Additional space: use Item 17, "Remarks," or attach a separate sheet, indicating the item number to which the answers apply.
Signature by mark: it must be witnessed by two persons to whom the signer is personally known.
Relationship: if not related, state "None".
Response: your obligation to respond is voluntary.
| Question | Answer |
|---|---|
| Form Name | VA Form 21P-4171 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 111 |
| Avg. time to fill out | 19 min |
| Edition | MAY 2024 |
| Where to send | Department of Veterans Affairs, Pension Intake Center, PO Box 5365, Janesville, WI 53547-5365 |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | VA Form 21P-4171, 21P-4171, VA 21P-4171, VA Form 21-4171, 21-4171, Supporting Statement Regarding Marriage |
| Official source | VA Form 21P-4171 (MAY 2024) |
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