Va Form 21 534 PDF Details

Are you a veteran seeking financial assistance from the Department of Veterans Affairs (VA), and looking to get started on the process? Whether you’re a newly discharged veteran or an existing client, completing VA Form 21-534 is one of the first steps in filing for Dependency and Indemnity Compensation (DIC). After all, knowing how to fill out VA Form 21-534 is essential to receive your deserved benefits. Read on as we take an in-depth look at what this form requires, what kind of information you will need to provide, and any documentation that must be submitted along with it.

Question	Answer
Form Name	Va Form 21 534
Form Length	12 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Other names	va 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?
SECTION I
		YES	NO	(If "Yes," answer Item 2)
Tell us what you
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)
the deceased				through 6)
veteran have
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

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

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

unless the veteran

mo day

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
SECTION III	time of his/her death.
	time of his/her death.

	21a. Entered Active			21b. Place	21c. Service Number
Tell us about the	Service (first period)
Tell us about the
veteran's active duty
service
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
all periods of service. If more		mo day	yr
space is needed use Item 48
space is needed use Item 48	21h. Entered Active			21i. Place	21j. Service Number
"Remarks."	21h. Entered Active			21i. Place	21j. Service Number
"Remarks."	Service (second		period)
	Service (second		period)
2. If the veteran never filed a
claim with VA, attach the		mo day	yr
original DD214 or a certified
original DD214 or a certified	21k. Left This Active			21l. Place	21m. Branch of Service	21n. Grade, Rank,
	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
Attach a copy of your	complete Items 22a through 27. If you are not the surviving spouse, skip to
marriage certificate showing
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,
	(first, middle	common-law, proxy,
	initial, last name)	common-law, proxy,
	initial, last name)	tribal or other
		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

If you answered "Yes," please explain.

23a. How many times were you married?

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

YES

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

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

(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

day

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
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.
Note: If you are filing this application
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 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
Tell us about	"Unknown" in the space.
the income of	"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
you and your	"None" in the space.
dependents	"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
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	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	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	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.	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	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	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	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.	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
	Source		(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:
	Sources of income	Surviving spouse or
	for the next 12	Surviving spouse or	(first, middle initial, last)	(first, middle initial, last)	(first, middle initial, last)
	months	Custodian of children
	months

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
	Tell us about medical,	deduction or nursing home costs you pay. Also, show unreimbursed last illness and burial expenses and
	last illness, burial or
	last illness, burial or	educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are
	other unreimbursed
	other unreimbursed	unreimbursed amounts paid by you for the veteran's or his/her child's last illness and burial and the
	expenses
	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
Give us direct		provide the information requested below in Items 41, 42 and 43 to enroll in direct deposit. If you
deposit information
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
If benefits are awarded we		contact representatives	handling waiver requests for the Department of Treasury at
will need more information		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
in order to process any		concerns you may have.
payments to you. Please read		concerns you may have.
payments to you. Please read
the paragraph starting with,
the paragraph starting with,		41. Account number (Please check the appropriate box and provide that account number, if applicable)
"The Department of
"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
1.	Attach a voided
	check, or
	check, or
2.	Answer questions 41-43	Account number
2.	Answer questions 41-43
	to the right.
	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
"I certify and authorize the	44. Your signature		45. Today's date
release of information:"	44. Your signature		45. Today's date
release of information:"
2. Sign the box that says,
"Your signature."
"Your signature."	46a. Signature of witness (If claimant	46b. Printed name and address of witness
	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")
then sign the form and
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
SECTION XII	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
APPLICATION FOR SURVIVORS BENEFITS
(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

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)

21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)

DEATH

MARRIAGE

AGE	(NAME)

OTHER (Specify)

(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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