OMB. Approved No. 2900-0004
Respondent Burden: 15 Minutes
Expiration Date: 10/31/2021
APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION BY A SURVIVING SPOUSE OR CHILD - IN-SERVICE DEATH ONLY
1.VETERAN'S NAME (First - Middle Initial - Last)
2.VETERAN'S SOCIAL SECURITY NO.
3.CLAIMANT'S NAME (First - Middle Initial- Last)
4.CLAIMANT'S SOCIAL SECURITY NO.
NOTE: When you file this application, you are telling us that you elect to receive Dependency and Indemnity Compensation (DIC) and all other service- connected death benefits to which you and/or the deceased veteran's children may be entitled.
5. FOR SURVIVING SPOUSE ONLY: If |
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have |
have not lived continuously with the veteran from date of marriage to date of death. |
not, answer Item 6. |
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6.CAUSE OF SEPARATION (Give reason, date of separation, and duration of separation. If separation was by Court order, attach a copy of such order.)
7.DATE OF BIRTH OF SURVIVING SPOUSE (MM, DD, YYYY)
8. CHILDREN OF THE DECEASED VETERAN (Natural, Step or Adopted) IN MY CUSTODY
DATE OF BIRTH
(Mo., Day, Yr.)
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PLACE OF BIRTH |
RELATIONSHIP TO CLAIMANT |
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(City and State) |
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9. CLAIMANT'S CURRENT MAILING ADDRESS
Street
Address
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Apt./Unit No. |
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City |
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State/Province |
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ZIP Code/Postal Code |
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10. CLAIMANT'S TELEPHONE NUMBERS (Including Area Code) |
11. CHANGE OF ADDRESS (Check applicable box) |
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I WILL BE CHANGING MY ADDRESS (If checked, complete Items 12 & 13) |
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DAYTIME |
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EVENING |
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I WILL NOT BE CHANGING MY ADDRESS |
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12. CLAIMANT'S NEW ADDRESS (If applicable) (If not applicable skip to Item 14) |
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13. DATE OF ADDRESS CHANGE |
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The Department of the Treasury requires all Federal benefit payments be made by electronic funds transfer (EFT), also called direct deposit. To enroll in direct deposit, provide the information requested below, AND attach either a voided personal check OR a deposit slip. If you DO NOT have a bank account, please visit https://www.benefits.va.gov/benefits/banking. asp. This website provides information about the Veterans Benefits Banking Program (VBBP), and a link to banks and credit unions that may fit your needs. You may also call 1-800-827-1000. If you elect not to enroll, you must contact representatives handling waiver requests for the Department of the Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any questions or concerns you may have.
14.I want do not want my VA payment to be directly deposited to my financial account.
15.FINANCIAL INSTITUTION INFORMATION FOR DIRECT DEPOSIT (Check one box) (If you do not want Direct Deposit skip to Item 16A)
CHECKING |
SAVINGS ACCOUNT NUMBER: |
NINE-DIGIT ROUTING OR TRANSIT NUMBER: |
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(Shown at the bottom left on your check) |
NAME OF FINANCIAL INSTITUTION (Provide the name of your bank):___________________________
I CERTIFY THAT the foregoing statements are true and complete to the best of my knowledge and belief.
16A. PRINTED NAME OF CLAIMANT
16B. SIGNATURE OF CLAIMANT (Sign in ink)
18. NAME AND RANK OF MILITARY CASUALTY ASSISTANCE OFFICER (CAO)
19.TELEPHONE NUMBER OF CAO (Include Area Code)
17.DATE SIGNED
20.E-MAIL ADDRESS OF CAO
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 to which you are not entitled.
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VA FORM |
21P-534A |
SUPERSEDES VA FORM 21-534A, JUN 2018, |
Page 1 |
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OCT 2018 |
WHICH WILL NOT BE USED. |
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INSTRUCTIONS FOR VA FORM 21P-534A
PRINT ALL ANSWERS CLEARLY.
SIGN AND DATE THE APPLICATION.
MAKE A PHOTOCOPY OF THIS APPLICATION AND EVERYTHING YOU SUBMIT TO VA BEFORE YOU MAIL IT.
FEES FOR CLAIMS: Section 5904, Title 38, United States Code (codified in § 14.636, Title 38, Code of Federal Regulations) contains provisions regarding fees that may be charged, allowed, or paid for services provided by a VA-accredited attorney or agent in connection with a proceeding before the Department of Veterans Affairs with respect to a claim for benefits under laws administered by the Department. Generally, a VA-accredited attorney or agent may charge you 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.
NOTE - All the information requested must be answered fully and clearly or action on your claim may be delayed. If you do not know the answer, write "unknown."
SPECIFIC INSTRUCTIONS
ITEMS 1-2 - Self-explanatory.
ITEM 3 - Name of surviving spouse or person applying on behalf of minor children.
ITEMS 4-12 -Self-explanatory.
ITEM 13 - Expected date that new mailing address will be effective.
ITEMS 14-17 - Self-explanatory.
ITEMS 18-20 - To be completed by Military Casualty Assistance Officer.
MINORS AND INCOMPETENT PERSONS - If the person for whom the claim is being made is a minor or incompetent person, the application 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.
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 at the time of marriage, or 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/.
THIS FORM, ALONG WITH THE SERVICEMEMBER'S DD FORM 1300, REPORT OF CASUALTY, SHOULD BE MAILED TO:
DEPARTMENT OF VETERANS AFFAIRS
PENSION INTAKE CENTER
P.O. BOX 5365
JANESVILLE, WI 53547-5365
For assistance in completing this application, or information about VA benefits and services, call us toll-free at
1-800-827-1000 (Hearing Impaired -TDD Line 1-800-829-4833).
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 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). VA will 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. 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 VA.
Respondent Burden: We need this information to determine eligibility for service connected death benefits under 38 U.S.C. 1310 through 1314. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 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 |
21P-534A |
Page 2 |
OCT 2018 |
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