Va Form 21 534 PDF Details

The VA Form 21-534 serves as a critical tool for surviving spouses or children seeking to claim various benefits in the aftermath of a veteran's death, encompassing Dependency and Indemnity Compensation (DIC), death pension, and any accrued benefits unclaimed before the veteran's passing. This comprehensive form also guides applicants through the process of applying for Social Security benefits, an additional piece affixed to the form's substantial guidance. It meticulously outlines who may qualify for these benefits under different circumstances, such as a service-connected death of the veteran, and introduces potential entitlements like the aid and attendance allowance, aimed at those needing regular assistance. The form places a strong emphasis on applicants understanding the importance of accurately completing the application and submitting it alongside all necessary documentation to facilitate the processing of their claim. It further details how one can designate a representative to aid in navigating the application process, offering an avenue for professional assistance. Equally, it touches upon recourse actions if disagreements arise regarding benefit determinations. As regulations and benefits may adjust over time, direct contact with the VA is encouraged for the most current information. VA Form 21-534 stands as a gateway for surviving family members to access deserved benefits, making its thorough completion and understanding paramount.

QuestionAnswer
Form NameVa Form 21 534
Form Length12 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min
Other namesva form 534, va form 21 534 pdf, va form 21 534 form, va aid and attendance form 21 534

Form Preview Example

GENERAL INSTRUCTIONS

FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION, DEATH PENSION AND ACCRUED BENEFITS BY A

SURVIVING SPOUSE OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)

VA FORM 21-534

Note: Read very carefully, detach, and keep these instructions for your reference.

A. How can I contact VA if I have questions?

If you have any questions about this form, how to fill it out, or about VA benefits, contact your nearest VA regional office. You can locate the address of the nearest regional office in your telephone book blue pages under "United States Government, Veterans" or call 1-800-827-1000 (Hearing Impaired TDD line 711). You may also contact VA by Internet at https:// iris.va.gov .

B. What is the purpose of VA Form 21-534?

Use VA Form 21-534 to apply for:

VA benefits you may be entitled to receive as a surviving spouse or child of a deceased veteran, and any money VA owes the veteran but did not pay prior to his/her death (accrued benefits).

If you apply for any one of these benefits, the law requires that we also consider you for the others.

C. What is the purpose of the attached SSA-24 form?

You can apply for Social Security (SS) benefits by using the SSA-24 form attached to this VA Form (see pages 9

and 10). You don't have to apply if you don't want to or have already done so. If you do want to apply, fill it out and leave it attached. We will send it to the Social Security Administration for you. They will then contact you.

D.What are dependency and indemnity compensation (DIC) and death pension benefits, and how does VA decide what I will or will not receive?

1.Dependency and indemnity compensation may be payable when:

a veteran's death occurred in service, or

a veteran dies of a service-connected disability, or in certain circumstances if a veteran rated totally disabled from service-connected disability dies from non-service-connected conditions.

2. Death pension may be payable when:

the death of a veteran with wartime service is not due to service, and

income is within applicable limits.

VA pays pension based on the amount of family income and the number of dependent children. This is based on law. VA must include as income all sources that Federal law specifies. If there is no surviving spouse, pension may be payable on behalf of a child or children.

Unless a claim for dependency and indemnity compensation or death pension is filed within one year from the date of the veteran's death, that benefit is not payable from a date earlier than the date the claim is received in the VA.

If it is determined that you are entitled to DIC and death pension, we will pay you whichever benefit entitles you to the most money. Benefit rates and income limits are frequently changed, so it is not possible to keep this information current in these instructions. You can find out what the current income limitations and rates of benefits are by contacting your nearest VA regional office.

E.How do I apply for aid and attendance allowance and/or housebound benefits?

VA may pay a higher rate of DIC or pension to a surviving spouse who is blind, a patient in a nursing home, otherwise needs regular aid and attendance, or who is permanently confined to his or her home because of a disability. If you wish to apply for this benefit, check "Yes" for Item 31.

F. How do I complete my application?

Print all answers clearly. If an answer is "none" or "0," write that. Your answer to every question is important to help us complete your claim. If you do not know the answer, write "unknown." For additional space, use Item 48, "Remarks, " or attach a separate sheet, indicating the item number to which the answers apply. Make sure you sign and date this application (Items 44 and 45).

Note: If the claim is being made on behalf of a minor or incompetent person, the application form should be completed and filed by the legal guardian. If no legal guardian has been appointed, it may be completed and filed by some person acting on behalf of the minor or incompetent person.

VA FORM

21-534

SUPERSEDES VA FORM 21-534, MAR 2009,

JUN 2014

 

WHICH WILL NOT BE USED.

General Instructions

PAGE 1

G. What do I do when I have completed my application?

When you have completed this application mail it or take it to a VA regional office. Be sure to attach any materials that support and explain your claim. Also, make a photocopy of your application and everything that you submit to VA before mailing it.

H. How can I assign someone to act as my representative?

A representative can be an accredited member of an accredited organization or other service organization that the Secretary of Veterans Affairs recognizes, an agent recognized by VA, or a licensed lawyer. Agents and attorneys can charge you for services that you get from them only after the Board of Veteran's Appeals (BVA) gives you their final decision about your application. That means you can use an attorney during any stage of your application for benefits. However, the agent or attorney cannot charge your for services unless you are trying to resolve a dispute with VA after BVA has made a decision about your claim.

If you want to use a representative to help you with your application, contact the nearest VA office. Depending on the type of representative you want to designate, we will send you one of the following forms:

VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, or VA Form 22A, Appointment of Individual as Claimant's Representative. You may also download these forms at www.va.gov/vaforms. If you have already designated a representative, no further action is required on your part.

I. What if I believe that VA has made an error in processing or deciding my benefits?

You can ask for a personal hearing at any time during the processing of your claim. That means you can ask for the hearing while VA is processing your claim or after VA has made a decision. You should contact the nearest VA office and tell them that you want a personal hearing on your case. Someone in the local VA office will arrange a time and place for your hearing. At this hearing, you can bring witnesses. VA will record whatever you and your witnesses say during the hearing and include it in the official record. VA will furnish the hearing room and officials, and prepare a transcript of the hearing. VA cannot pay your expenses or the expenses of anyone you want to bring with you to the hearing.

IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for benefits) (38 U.S.C. § 103 (c)). Additional guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.

PRIVACY ACT INFORMATION: The 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 required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). The VA will l not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. 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 that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any amount owed to the United States by virtue of your participation in any benefit program administered by the Department of Veterans Affairs.

RESPONDENT BURDEN: We need this information to determine eligibility for death benefits and accrued benefits under 38 U.S.C. 1310 through 1314, 1532 through 1543, and 5121. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 1 hour and 15 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 to get information on where to send comments or suggestions about this form.

VA FORM 21-534, JUN 2014

General Instructions

PAGE 2

Application for Dependency and Indemnity Compensation, Death Pension and Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable) VA Form 21-534

Please read the attached "General Instructions" before you fill out this form.

OMB Approved No. 2900-0004 Respondent Burden: 1 hour 15 minutes Expiration Date: 1/31/2015

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

SECTION I

1. Did the veteran ever file a claim with VA?

2. What is the VA file number?

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

(If "Yes," answer Item 2)

 

 

 

 

 

Tell us what you

 

 

 

 

 

 

 

 

 

3. Has the surviving spouse or child ever filed a

4. What is the VA file number?

are applying for

 

claim with VA?

 

 

 

 

 

 

 

and what you and

 

 

 

(If "Yes," answer Items 4

 

 

 

 

 

the deceased

 

YES

NO

through 6)

 

 

 

 

 

 

 

 

 

 

 

 

 

veteran have

 

 

 

 

 

 

 

5. What is the name of the person on whose service the claim was filed?

applied for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

Middle

 

Last

6.What is your relationship to that person?

7.Are you claiming service connection for cause of death?

YES NO

SECTION II

 

8. What is the veteran's name?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tell us

 

 

 

 

 

First

 

 

 

Middle

 

 

Last

 

 

Suffix (If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

about you

 

9. What is the veteran's Social Security number?

10a. Did the veteran serve under another name?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

deceased

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If "Yes," answer Item 10b)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

veteran

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10b. Please list the other name(s) the veteran

11. What is the veteran's date of birth?

 

 

 

 

 

 

served under:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo day

yr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach a copy of the

 

12. What is the veteran's date of death?

13. Was the veteran a former prisoner of war?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

death certificate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

unless the veteran

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo day

yr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

died in active service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of the Army, Navy,

 

14. What is your name? (First, Middle, Last Name)

15. What is your relationship to the veteran?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Air Force, Marine Corps,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Coast Guard, or in a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Surviving Spouse

Child

U.S. government

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. What is your address?

 

 

 

 

 

 

 

 

 

 

institution.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address, Rural Route, or P.O. Box

 

 

 

 

 

Apt. number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

ZIP Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. What are your telephone numbers?

18. What is your e-mail address?

 

 

 

 

 

 

 

(Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evening

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. What is your Social Security number?

20. What is your date of birth?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo day yr

 

 

 

 

 

 

VA FORM

21-534

 

 

 

 

SUPERSEDES VA FORM 21-534, MAR 2009,

 

 

 

 

 

 

 

PAGE 1

JUN 2014

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHICH WILL NOT BE USED.

 

 

 

 

 

 

 

 

 

 

SECTION III

Note: Skip to Section IV if the veteran was receiving VA compensation or pension at the

time of his/her death.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21a. Entered Active

21b. Place

21c. Service Number

 

Tell us about the

Service (first period)

 

 

 

 

 

 

 

 

 

 

veteran's active duty

 

 

 

 

 

 

 

service

 

 

 

 

 

 

 

mo day

yr

 

 

 

 

 

 

 

 

 

 

21d. Left This Active

21e. Place

21f. Branch of Service

21g. Grade, Rank,

 

Service

 

 

 

 

or Rating

1. Enter complete information for

 

 

 

 

 

 

 

all periods of service. If more

 

 

 

 

 

 

 

 

mo day

yr

 

 

 

space is needed use Item 48

 

 

 

 

 

 

 

21h. Entered Active

21i. Place

21j. Service Number

 

"Remarks."

 

Service (second

period)

 

 

 

 

 

 

 

2. If the veteran never filed a

 

 

 

 

 

 

 

claim with VA, attach the

 

mo day

yr

 

 

 

original DD214 or a certified

 

 

 

 

 

 

 

21k. Left This Active

21l. Place

21m. Branch of Service

21n. Grade, Rank,

 

copy for each period of service

Service

 

 

 

 

or Rating

listed. We will return original

 

 

 

 

 

 

 

documents to you.

 

 

 

 

 

 

 

 

 

mo day

yr

 

 

 

 

 

 

 

 

 

 

 

SECTION IV

 

 

 

 

 

 

 

 

You must furnish complete information about all marriages of the surviving

Tell us about

spouse and the veteran. If you need additional space, please attach a separate

your and the veteran's

sheet of paper providing the requested information.

 

marriages

 

 

 

 

 

 

 

Attach a copy of your

If you are claiming benefits as the surviving spouse of the veteran you should

complete Items 22a through 27. If you are not the surviving spouse, skip to

marriage certificate showing

 

 

 

 

 

 

 

your marriage to the veteran.

Section V.

 

 

 

 

 

 

 

 

 

 

 

 

 

The veteran's marriages

22a. How many times was the veteran married?

22b. Date of Marriage

(month, day, year)

22c. Place (city/state or country)

22d. To whom married

22e. Type of marriage

(first, middle

(ceremonial,

common-law, proxy,

initial, last name)

tribal or other

 

 

 

22f. Date marriage ended (month, day, year)

22g. Place (city/state

or country)

22h. How marriage ended (death, divorce)

22i. If you indicated "other" as type of marriage, please explain.

22j. At the time of your marriage to the veteran, were you aware of any reason the marriage might not be legally valid?

 

 

 

YES

NO

If you answered "Yes," please explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23a. How many times were you married?

 

 

23b. Have you remarried since the death of the veteran?

YES

NO

 

 

 

 

 

 

23c. Date of

23d. Place (city/state

23e. To whom married

23f. Type of marriage

23g. Date marriage

23h. Place (city/state

23i. How marriage

Marriage

or country)

(first, middle

 

(ceremonial,

ended

or country)

 

 

ended (death,

(month, day, year)

 

 

initial, last name)

 

common-law, proxy,

(month, day, year)

 

 

 

divorce)

 

 

 

tribal or other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23j. If you indicated "other" as type of marriage, please explain.

VA FORM 21-534, JUN 2014

PAGE 2

SECTION IV Tell us about your and the veteran's marital history (continued)

Answer Item 24 only if you

 

 

24.

Was a child born to you and the veteran

25.

Are you expecting the birth of a child of

 

 

 

during your marriage or prior to your

 

 

the veteran?

 

 

 

 

were married to the veteran

 

 

 

 

 

 

 

 

 

 

 

 

marriage?

 

 

 

 

 

 

 

 

 

 

 

for less than one year.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26.

Did you live continuously with the

 

27.

What was the cause of the separation?

 

 

 

 

 

 

 

veteran from the date of marriage to the

 

 

Give the reason, date(s), and duration of the

 

 

 

 

 

 

 

date of his/her death?

 

 

separation. If the separation was by court

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

order, attach a copy of the order.

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If "No", answer Item 27)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION V

 

 

 

 

Note: Skip to Section VI if you are not claiming benefits for any children that meet the

 

 

 

 

 

 

following criteria.

 

 

 

 

 

 

 

 

Tell us about the

 

 

 

 

VA recognizes the veteran's biological children, adopted children, and stepchildren as

 

 

unmarried children

 

 

 

 

 

 

 

 

 

 

dependents. These children must be unmarried and:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of the veteran

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

under age 18, or

 

 

 

 

 

 

 

 

Note: You should provide a copy

 

 

 

 

 

at least 18 but under 23 and pursuing an approved course of education, or

 

 

 

 

 

 

 

of any age if they became permanently unable to support themselves before

 

 

of the public record of birth or a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reaching age 18.

 

 

 

 

 

 

 

 

copy of the court record of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

adoption for each child listed in

 

 

"Seriously disabled" (Item 29e) means that the child became permanently unable to support

Item 28a unless the veteran was

 

 

 

 

himself/herself before reaching age 18. Furnish a statement from an attending physician or

receiving additional VA benefits

 

 

 

 

other medical evidence which shows the nature and extent of the physical or mental impairment.

for the child.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need additional space,

 

 

Note to surviving spouse: If entitlement to DIC is established, a "seriously disabled" child over

 

 

 

 

 

 

please attach a separate sheet of

 

 

age 18 is entitled to receive DIC benefits in his or her own right. A veteran's child who is

 

 

 

 

 

 

paper providing the requested

 

 

seriously disabled and over age 18 must submit a separate VA Form 21-534 to apply for benefits.

 

 

 

 

 

 

information about each child.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28a. Name of child

 

28b. Date and place

 

 

28c. Social Security

29a.

 

29b.

 

29c.

29d. 18 -

29e.

29f. Child

(First, middle initial,

 

of birth (City/State or

 

 

Number

 

Biological

 

Adopted

 

Stepchild

23 yrs old

Seriously

previously

Last)

 

Country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and in

disabled

married

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

school

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo

day

yr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo

day

yr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo

day

yr

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM 21-534, JUN 2014

PAGE 3

SECTION V Tell us about the unmarried children of the veteran (continued)

Tell us about the children listed above that don't live with you.

30a. Name of child

(first, middle initial, last)

30b. Child's Complete Address

30c. Name of person the child lives with (if applicable)

30d. Monthly amount you contribute to child's support

$

$

$

$

SECTION VI

Tell us if

you are housebound, in a nursing home or require aid and attendance

If you answered "yes" to Item 31 and are not in a nursing home, submit a statement from your doctor showing the extent of your disabilities. If you are in a nursing home, attach a statement signed by an official of the nursing home showing the date you were admitted to the nursing home, the level of care you receive, the amount you pay out- of-pocket for your care, and whether Medicaid covers all or part of your nursing home costs.

31. Are you claiming aid and attendance

32a. Are you now in a nursing home?

allowance and/or housebound benefits

 

 

because you need the regular assistance of

 

 

another person, are having severe visual

 

 

problems, or are housebound?

 

 

YES

NO

YES

NO

(If "No," skip to section VII)

(If "Yes," answer Items 32b and 32c also)

 

 

32b. What is the name and complete mailing

32c. Does Medicaid cover all or part of your

address of the facility?

nursing home costs?

 

 

YES

NO

 

 

(If "No," answer Item 32d also)

32d. Have you applied for Medicaid?

YES NO

VA FORM 21-534, JUN 2014

PAGE 4

SECTION VII

VA cannot pay you pension if your net worth is sizeable. Net worth is the market value of

 

 

all interest and rights you have in any kind of property less any mortgages or other claims

Tell us the net

against the property. However, net worth does not include the house you live in or a

worth of you and

reasonable area of land it sits on. Net worth also does not include the value of personal

your dependents

things you use everyday like your vehicle, clothing, and furniture. You must report net

 

 

Note: If you are filing this application

worth for yourself and all persons for whom you are claiming benefits.

 

 

 

 

 

 

 

on behalf of a minor or incompetent

For Items 33a through 33f, provide the amounts. If none, write "0" or "None."

child of the veteran and you are the

 

 

 

 

 

 

 

child's custodian, you must report your

 

 

 

 

 

 

 

net worth as well as the net worth of the

 

 

 

 

 

 

 

child for whom benefits are claimed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child(ren)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

Name:

 

Name:

Source

Surviving spouse or

(first, middle initial, last)

 

(first, middle initial, last)

(first, middle initial, last)

 

 

Custodian of children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33a. Cash, bank accounts, certificates

 

 

 

 

 

 

 

of deposit (CDs)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33b. IRAs, Keogh Plans, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33c. Stocks, bonds, mutual funds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33d. Value of business assets

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33e. Real property (not your home)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33f. All other property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION VIII

Report the total amounts before you take out deductions for taxes, insurance, etc.

 

 

Do not report the same information in both tables.

 

 

Tell us about

If you expect to receive a payment, but you don't know how much it will be, write

"Unknown" in the space.

 

 

 

 

the income of

 

 

 

 

If you do not receive any payments from one of the sources that we list, write "0" or

you and your

"None" in the space.

 

 

 

 

dependents

 

 

 

 

If you are receiving monthly benefits, give us a copy of your most recent award letter.

 

 

 

 

This will help us determine the amount of benefits you should be paid.

Payments from any source will be

 

 

 

 

 

 

 

 

 

34a. Have you claimed or are you receiving

34b. Is Social Security based on your own

counted, unless the law says that they

benefits from the Social Security

 

employment?

 

 

don't need to be counted. Report all

 

 

 

Administration on your own behalf or on

 

 

 

 

income, and VA will determine any

 

 

 

 

behalf of child(ren) in your custody?

 

 

 

 

amount that does not count.

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

YES

NO

 

 

(If "Yes," answer item 34b)

 

 

 

 

 

 

 

 

 

 

 

 

Note: If you are filing this application

 

35. Has a surviving spouse or child filed a

36. Has a court awarded damages based on

on behalf of a minor of whom you are

claim for compensation from the Office of

 

the death of the veteran or is a claim or

the custodian, you must report your

 

Worker's Compensation Programs based

 

legal action for damages pending?

income as well as the income of each

 

on the death of the veteran?

 

 

 

 

child for whom benefits are claimed.

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

YES

NO

 

 

 

 

 

 

 

 

 

37.Have you claimed or are you receiving Survivor Benefit Plan (SBP) annuity from a service department based on the death of the veteran?

YES NO

VA FORM 21-534, JUN 2014

PAGE 5

SECTION VIII Tell us about the income of you and your dependents (continued)

Monthly Income - Tell us the income you and your dependents receive every month

 

 

 

 

Child(ren)

 

 

 

 

 

 

 

 

 

 

Name:

Name:

Name:

 

Source

Surviving spouse or

 

 

 

 

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

 

 

Custodian of children

 

 

 

 

 

 

 

 

38a.

Social Security

 

 

 

 

 

 

 

 

 

 

38b.

U.S. Civil Service

 

 

 

 

 

 

 

 

 

38c. U.S. Railroad Retirement

 

 

 

 

 

 

 

 

 

 

38d.

Military Retirement

 

 

 

 

38e. Black Lung Benefits

38f. Supplemental Security Income

(SSI)/ Public Assistance

38g. Other income received monthly

(Please write source below:)

Expected income next 12 months - Tell us about other income for you and your dependents

Report expected income for the 12 month period following the veteran's death. If the claim is filed more than one year after the veteran died, report the expected income for the 12 month period from the date you sign this application.

 

 

 

 

Child(ren)

 

 

Sources of income

 

Name:

Name:

Name:

 

Surviving spouse or

 

 

 

 

for the next 12

(first, middle initial, last)

(first, middle initial, last)

(first, middle initial, last)

 

months

Custodian of children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

39a.

Gross wages and salary

 

 

 

 

 

 

 

 

 

 

39b.

Total dividends and interest

 

 

 

 

 

 

 

 

 

39c. Other income expected

 

 

 

 

(Please write source below:)

 

 

 

 

 

 

 

 

 

 

39d.

Other income expected

 

 

 

 

(Please write source below:)

 

 

 

 

 

 

 

 

 

 

VA FORM 21-534, JUN 2014

PAGE 6

SECTION IX

Family medical expenses and certain other expenses actually paid by you may be deductible from your

 

Tell us about medical,

income. Show the amount of any continuing family medical expenses such as the monthly Medicare

deduction or nursing home costs you pay. Also, show unreimbursed last illness and burial expenses and

last illness, burial or

educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are

other unreimbursed

unreimbursed amounts paid by you for the veteran's or his/her child's last illness and burial and the

expenses

 

 

veteran's just debts. Educational or vocational rehabilitation expenses are amounts paid for courses of

 

education, including tuition, fees, and materials. Do not include any expenses for which you were

 

reimbursed. If you receive reimbursement after you have filed this claim, promptly advise the VA office

 

handling your claim. If more space is needed attach a separate sheet.

 

 

40a. Amount paid by

40b. Date Paid

40c. Purpose (Medicare

40d. Paid to (Name of

40e. Relationship of person for

you

 

deduction, nursing

nursing home,

whom expenses paid

 

 

home costs, burial

hospital, funeral

 

 

 

expenses, etc.)

home, etc.)

 

$

 

 

 

 

 

 

 

 

 

 

mo

day

yr

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

mo

day

yr

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

mo

day

yr

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

mo

day

yr

SECTION X

The Department of Treasury requires all Federal benefit payments be made by electronic funds

 

 

Give us direct

transfer (EFT), also called direct deposit. Please attach a voided personal check or deposit slip or

provide the information requested below in Items 41, 42 and 43 to enroll in direct deposit. If you

deposit information

do not have a bank account, you must receive your payment through Direct Express Debit

 

 

 

 

MasterCard. To request a Direct Express Debit MasterCard you must apply at www.

If benefits are awarded we

usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to enroll, you must

contact representatives

handling waiver requests for the Department of Treasury at

will need more information

1-888-224-2950. They will encourage your participation in EFT and address any questions or

in order to process any

concerns you may have.

 

 

payments to you. Please read

 

 

 

 

 

 

the paragraph starting with,

 

 

 

 

41. Account number (Please check the appropriate box and provide that account number, if applicable)

"The Department of

 

 

 

 

Treasury..." and then either:

Checking

I certify that I do not have an account with a financial

1.

Attach a voided

Savings

institution or certified payment agent

 

 

 

check, or

 

 

 

 

 

 

 

2.

Answer questions 41-43

Account number

 

 

 

 

 

 

 

to the right.

 

 

 

 

 

 

 

 

 

42.Name of financial institution

43.Routing or transit number

VA FORM 21-534, JUN 2014

PAGE 7

SECTION XI

I certify and authorize the release of information:

 

 

 

I certify that the statements in this document are true and complete to the best of my knowledge. I

Give us your

authorize any person or entity, including but not limited to any organization, service provider,

signature

employer, or government agency, to give the Department of Veterans Affairs any information about

 

me except protected health information, and I waive any privilege which makes the information

1. Read the box that starts,

confidential.

 

 

"I certify and authorize the

 

 

 

 

44. Your signature

 

45. Today's date

release of information:"

 

 

 

 

 

2. Sign the box that says,

 

 

 

 

"Your signature."

 

 

 

 

46a. Signature of witness (If claimant

 

46b. Printed name and address of witness

 

 

 

signed above using an "X")

 

 

 

3. If you sign with an "X,"

 

 

 

 

then you must have 2

 

 

 

 

people you know witness

 

 

 

 

you as you sign. They must

47a. Signature of witness (If claimant

 

47b. Printed name and address of witness

then sign the form and

signed above using an "X")

 

 

 

 

 

 

 

print their names and

 

 

 

 

addresses also.

 

 

 

 

 

 

 

 

SECTION XII

48. Remarks (If you need more space to answer a question or have a comment about a specific item number

on this form please identify your answer or statement by the part and item number)

Remarks - Use this

 

 

 

 

space for any additional

 

 

 

 

statements that you

 

 

 

 

would like to make

 

 

 

 

concerning your

 

 

 

 

application.

 

 

 

 

IMPORTANT

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, or for the fraudulent acceptance of any payment which you are not entitled to.

VA FORM 21-534, JUN 2014

PAGE 8

 

 

Form Approved

 

 

OMB Approved No. 0960-0062

 

 

 

SOCIAL SECURITY ADMINISTRATION

 

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR SURVIVORS BENEFITS

VA DATE STAMP

 

(PAYABLE UNDER TITLE II OF THE SOCIAL SECURITY ACT)

 

IMPORTANT - Read instructions before completing form. Detach and retain ONLY the instruction sheet.

 

 

 

 

1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

2. DATE OF DEATH

 

 

 

 

NOTE: If the veteran's Social Security No. is unknown, complete Items 4, 5, 6 and 7 about veteran.

3. SOCIAL SECURITY NO. OF VETERAN

4. DATE OF BIRTH

5. PLACE OF BIRTH

 

 

 

6. NAME OF FATHER

7. MAIDEN NAME OF MOTHER

8.DID THE VETERAN WORK IN THE RAILROAD INDUSTRY AT ANY TIME AFTER 1936?

YES

NO

NOTE: The following information should be furnished for each period of the veteran's active service (regular or reserves) after September 7, 1939, in the military service of the United States or service as a commissioned officer in the Public Health Service or the National Oceanic and Atmospheric Administration or during WWII, Philippine or Filipino or Allied country military service. If additional space is needed, attach a separate sheet.

9A. DATE ENTERED ACTIVE SERVICE

9B. SERVICE NO.

9C. DATE SEPARATED FROM ACTIVE

SERVICE

9D. GRADE, RANK, OR RATING, ORGANIZATION

AND BRANCH OF SERVICE

10. RELATIONSHIP OF APPLICANT TO VETERAN

 

SURVIVING SPOUSE

CHILD

PARENT

11. DATE OF BIRTH OF APPLICANT

12. VA FILE NO.

CHILDREN: Show names of surviving children (including natural children, adopted children and stepchildren) or dependent grandchildren (including stepgrandchildren) who at any time since the veteran died, were unmarried and (a) under age 18; (b) age 18 to 19 and attending secondary school; (c) disabled or handicapped (18 or over and disability began before age 22).

13A.

13C.

13B.

13D.

I know that anyone who makes or causes to be made a false statement or representation of a material fact in an application or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. I affirm that all information I have given in this document is true.

14.DATE (Month, day, year)

15.SIGNATURE OF APPLICANT (First name, middle initial, last name) (Sign in ink)

16.MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., State and ZIP Code)

17.TELEPHONE NO. (Include Area Code)

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE

18A. SIGNATURE OF WITNESS

18B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

19A. SIGNATURE OF WITNESS

19B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"

20. PROOFS RECEIVED

DEATH

AGE

OTHER (Specify)

MARRIAGE

(NAME)

(NAME)

(NAME)

21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)

DEATH

MARRIAGE

AGE

(NAME)

 

OTHER (Specify)

(NAME)

(NAME)

22. DATE

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

Form SSA-24 (2-2002) Destroy All Prior Editions

PAGE 9

IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.

INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS

(Payable Under Title II of the Social Security Act)

This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the Social Security Act, as amended. Under authority of section 202(o) of the Social Security Act, the application requests information in order to determine eligibility to social security benefits.

You do not have to complete this application; there are no penalties under the law if you do not complete part or all of the SSA-24. However, it is usually to your advantage to provide the information because not providing it could prevent an accurate and timely decision on your claim or could result in the loss of some benefits or insurance coverage.

If you do wish to supply the information requested on the SSA-24, this information will be forwarded to the Social Security Administration and used by them to determine whether social security benefits may be payable to surviving dependent(s) of the veteran. Social Security will then contact you regarding any social security benefits payable based on information given on this form.

Please understand that Social Security may, in certain instances, disclose the information on this form to another Federal, State or local agency or individual without your written consent. This would be done in order to:

enable a third party or an agency to assist Social Security in establishing an individual's right to benefits or coverage;

comply with Federal laws which require or authorize the release of information from social security records; and

facilitate statistical research and audit activities necessary to assure the integrity and improvement of the social security programs.

If you should have any question about entitlement to social security benefits or the information you have provided on this form, please contact your local social security office.

Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When signed and dated the form SHOULD BE LEFT ATTACHED to your completed

VA Form21-534, Application for Dependency and Indemnity Compensation, Death Pension a nd Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable) or

VA Form 21-535, Application for Dependency and Indemnity Compensation by Parent(s) (Including Accrued Benefits and Death Compensation When Applicable).

PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 15 minutes to read the instructions, gather the necessary facts, and answer the questions.

PAGE 10

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