Va Form 21 534Ez – Fill Out and Use This PDF

The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed, and there is no risk to participate!

Participation in the FDC Program is optional and will not affect the quality of care you receive or the benefits to which you are entitled. If you file a claim in the FDC Program and it is determined that other records exist and VA needs the records to decide your claim, then VA will simply remove the claim from the FDC Program (Optional Expedited Process) and process it in the Standard Claim Process. See below for more information. If you wish to file your claim in the FDC Program, see FDC Program (Optional Expedited Process). If you wish to file your claim under the process in which VA traditionally processes claims, see Standard Claim Process.

WHAT YOU NEED TO DO

You must submit all relevant evidence in your possession and provide VA information sufficient to enable it to obtain all relevant evidence not in your possession. If your claim involves a disability the veteran had before entering service and that was made worse by service, please provide any information or evidence in your possession regarding the health condition that existed before the veteran's entry into service.

HOW VA WILL HELP YOU OBTAIN EVIDENCE FOR YOUR CLAIM

WHEN YOU SHOULD SEND WHAT WE NEED

WHERE TO SEND INFORMATION AND EVIDENCE

Mail or take your application and any evidence in support of your claim to the closest VA regional office. VA regional office addresses are available on the Internet at www.va.gov/directory.

WHAT THE EVIDENCE MUST SHOW TO SUPPORT YOUR CLAIM

Death Pension

To support your claim for death pension benefits, the evidence must show:

1.The veteran met certain minimum requirements regarding active service during a period of war. Generally, those requirements involve:

•90 days of consecutive service, at least one day of which was during a period of war; OR

•90 days of combined service during at least one period of war;

(Note : If the veteran's service began after September 7, 1980, additional length-of-service requirements may apply, typically requiring two years of continuous service or completion of active-duty obligations.)

OR any length of active service during a period of war when:

•At the time of death, the veteran was receiving (or entitled to receive) VA disability compensation or retirement pay for a service-connected disability; OR

•The veteran was discharged from active service due to a service-connected disability.

2.Your net worth and income do not exceed certain requirements.

Dependency and Indemnity Compensation (DIC)

To support a claim for Dependency and Indemnity Compensation (DIC) benefits based on a service-connected disability established during the veteran's lifetime, the evidence must show:

•The veteran died while on active service; OR

•The veteran had a service-connected disability(ies) that was either the principal or contributory cause of the veteran's death; OR

•The veteran died from non service-connected injury or disease AND was receiving, or entitled to receive VA compensation for a service-connected disability rated totally disabling:

•For at least 10 years immediately before death; OR

•For at least 5 years after the veteran's release from active duty preceding death; OR

•For at least 1 year before death, if the veteran was a former prisoner of war who died after September 30, 1999

To support a claim for DIC benefits based on a disability that was not service-connected or for which the veteran did not file a claim during his or her lifetime, the evidence must show:

•An injury or disease that was incurred or aggravated during active service, or an event in service that caused an injury or disease; AND

•A physical or mental disability that was either the principle or contributory cause of death. This may be shown by

medical evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND

•A relationship between the disability associated with the cause of death and an injury, disease, or event in service. This may be shown by medical records or medical opinion or, in certain cases, by lay evidence

EVIDENCE TABLES (Continued)

Dependency and Indemnity Compensation (DIC) (Continued)

To support your claim for DIC benefits based upon the service person's active duty for training, the evidence must show:

•The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty, and the disease or injury caused or contributed to the service person's death.

If VA granted service connection for a disease or injury during the service person's lifetime, evidence that the service-connected disease or injury caused or contributed to the service person's death may satisfy this requirement.

To support a claim for DIC benefits based on a disability that was not service-connected or for which the service person did not file a claim during his or her lifetime, the evidence must show:

•The service person was disabled during active duty for training due to a disease or injury incurred in the line of duty; AND

•A physical or mental disability that was either the principle or contributory cause of death. This may be shown by medical evidence or by lay evidence of persistent and recurrent symptoms of disability that were visible or observable; AND

•A relationship between the principal or contributory cause of death and the disability due to injury or disease, incurred in the line of duty. This may be shown by medical records or medical opinions or, in certain cases, by lay evidence.

To support your claim for DIC benefits based upon the service person's inactive duty training, the evidence must show:

•The service person died during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute myocardial infarction, cardiac arrest, or cerebrovascular accident during such training; OR

•The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; and that injury, acute myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service person's death

If VA granted service connection for an injury, acute myocardial infarction, or cerebrovascular accident during the service person's lifetime, evidence that the service-connected condition caused or contributed to the service person's death may satisfy this requirement.

To support a claim for DIC benefits based on a disability that was not service-connected or for which the service person did not file a claim during his or her lifetime, the evidence must show:

•The service person was disabled during inactive duty training due to an injury incurred or aggravated in the line of duty, or acute myocardial infarction, cardiac arrest, or cerebrovascular accident that occurred during such training; AND

•The injury, acute myocardial infarction, cardiac arrest, or cerebrovascular accident caused or contributed to the service person's death

DIC under 38 U.S.C. 1151:

In order to support your claim for DIC under 38 U.S.C. 1151, the evidence must show:

•The deceased veteran died as a result of undergoing VA hospitalization, medical or surgical treatment, examination, or training; AND

•The death was:

•the direct result of VA fault such as carelessness, negligence, lack of proper skill, or error in judgment; OR

•the direct result of an event that was not a reasonably expected result or complication of the VA care or treatment; OR

•the direct result of participation in a VA Vocational Rehabilitation and Employment or compensated work therapy program

Reopened DIC:

In order to reopen a claim previously denied by VA, we need new and material evidence. New and material evidence must raise a reasonable possibility of substantiating your claim. The evidence cannot simply be repetitive or cumulative of the evidence we had when we previously decided your claim. VA will make reasonable efforts to help you obtain currently existing evidence.

However, we cannot provide a medical examination or obtain a medical opinion until your claim is successfully reopened.

•To qualify as new, the evidence must currently exist and be submitted to VA for the first time

•In order to be considered material, the additional existing evidence must pertain to the reason your claim was previously denied

EVIDENCE TABLES (Continued)

Increased Survivor Benefits Based on Need for Aid and Attendance or Being Housebound

In order to support your claim for increased survivor benefits based on the need for aid and attendance, the evidence must show:

•you have corrected vision of 5/200 or less in both eyes; OR

•you have concentric contraction of the visual field to 5 degrees; OR

•you are a patient in a nursing home due to mental or physical incapacity; OR

•you require the aid of another person in order to perform personal functions required in everyday living, such as bathing, feeding, dressing yourself, attending to the wants of nature, adjusting prosthetic devices, or protecting yourself from the hazards of your daily environment (38 Code of Federal Regulation 3.352(a)); OR

•you are bedridden, in that your disability or disabilities requires that you remain in bed apart from any prescribed course of convalescence or treatment (38 Code of Federal Regulation 3.352(a)); OR

In order to support your claim for increased benefits based on being housebound, the evidence must show:

• you are substantially confined to your immediate premises because of permanent disability

Accrued Benefits:

To support a claim for accrued benefits, the evidence must show:

•Benefits were due the veteran based on existing ratings, decisions, or evidence in VA's possession at the time of death, but the benefits were not paid before the veteran's death; AND

•You are the surviving spouse, child, or dependent parent of the deceased veteran

VA pays accrued benefits in the following order of priority:

1.Spouse

2.Children of the veteran (in equal shares)

3.Dependent parents (in equal shares)

Helpless Child:

To support a claim for benefits based on a veteran's child being helpless, the evidence must show that the child, before his or her 18th birthday, became permanently incapable of self-support due to a mental or physical disability.

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/.

HOW VA DETERMINES THE EFFECTIVE DATE

If we grant a claim for death benefits, the beginning date of your entitlement will generally be based on when we received your claim However, if VA received your claim within one year of the date of the veteran's death, entitlement will be from the first day of the month in which the veteran died.

The veteran's death certificate is evidence relevant to determining the effective date of any benefits we award.

Higher levels of benefits are available for a veteran's surviving spouse and/or parents who are unable to perform certain activities of daily living or leave their home. Higher levels of benefits may be effective from the date medical evidence first establishes entitlement.

For more information on the FDC Program, visit our web site at http://benefits.va.gov/transformation/fastclaims/ For more

information on VA benefits, visit our web site at www.va.gov, contact us at http://iris.va.gov, or call us toll-free at 1-800-827-1000. If you use a Telecommunications Device for the Deaf (TDD), the number is 1-800-829-4833.

VA forms are available at www.va.gov/vaforms.

OMB Control No. 2900-0004

Respondent Burden: 25 minutes

Expiration Date: 1/31/2015

VA DATE STAMP

(DO NOT WRITE IN THIS SPACE)

APPLICATION FOR DIC, DEATH PENSION,

AND/OR ACCRUED BENEFITS

IMPORTANT: Please read the Privacy Act and Respondent Burden on page 11 before completing the form.

SECTION I: PERSONAL INFORMATION (MUST COMPLETE)

16. WHAT ARE YOU CLAIMING? (Check all that apply)

SECTION III- MARITAL INFORMATION (COMPLETE ONLY IF CLAIMING BENEFITS AS

THE SURVIVING SPOUSE OF THE VETERAN)

(Skip to Section IV if you are NOT claiming benefits as the surviving spouse of the veteran)

TELL US ABOUT THE VETERAN'S MARRIAGES

21A. HOW MANY TIMES WAS THE VETERAN MARRIED (including marriage to you)?

21G. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 21D, PLEASE EXPLAIN:

TELL US ABOUT YOUR MARRIAGES

22H. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22E, PLEASE EXPLAIN:

27. AT THE TIME OF YOUR MARRIAGE TO THE VETERAN, WERE YOU AWARE OF ANY REASON THE MARRIAGE MIGHT NOT BE LEGALLY VALID?

SECTION IV: DEPENDENT CHILDREN (COMPLETE ONLY IF CLAIMING BENEFITS FOR A CHILD(REN) OF THE VETERAN) (Skip to Section V if you are NOT claiming benefits for a child(ren) of the veteran)

If claiming benefits as the surviving spouse or custodian filing for a child, in items 29A through 29D tell us about the children listed in Item 28A who do not live with you.

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SECTION V: VETERAN'S PARENT (COMPLETE ONLY IF CLAIMING BENEFITS AS THE PARENT OF VETERAN)

(Skip to Section VI if you are NOT claiming benefits as the parent of a veteran)

30B. IF YOUR MARRIAGE HAS ENDED, PLEASE SPECIFY THE DATE (month, day, year) AND HOW MARRIAGE ENDED (death, divorce)

30C. IF YOU ARE SEPARATED, WHAT WAS THE CAUSE OF THE SEPARATION? GIVE THE REASON, DATE(S) AND DURATION OF THE SEPARATION (IF THE

SEPARATION WAS BY COURT ORDER, ATTACH A COPY OF THE ORDER)

32C. WHY WASN'T THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE AGE OF MAJORITY? (Explain fully)

33. NAME AND ADDRESS OF EACH PERSON WHO ASSUMED PARENTAL CONTROL OVER THE VETERAN OUTSIDE THE DATE(S) SHOWN IN ITEM 32B

34.IF YOU ARE NOT THE BIOLOGICAL PARENT OF THE VETERAN, PROVIDE THE NAMES OF THE BIOLOGICAL PARENTS, IF DECEASED, PROVIDE THE DATE OF DEATH.

SECTION VI: DIC (COMPLETE ONLY IF CLAIMING DEPENDENCY AND INDEMNITY COMPENSATION (DIC))

(Skip to Section VII if you are NOT claiming DIC)

35. WHAT BENEFIT ARE YOU CLAIMING?

36. LIST ANY VA MEDICAL CENTERS WHERE THE VETERAN RECEIVED TREATMENT PERTAINING TO YOUR CLAIM AND PROVIDE TREATMENT DATES:

SECTION VII: NET WORTH (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)

(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)

37. NET WORTH (DO NOT LEAVE ANY ITEMS BLANK. If your household has no net worth in a particular source, write "0" or "none")

Report total net worth for your household. Identify the specific owner for each net worth source, yourself or another person in your household, as applicable. If you are the custodian filing for a child of the veteran, you must report your net worth and the child's net worth, if any.

SECTION VIII: GROSS MONTHLY INCOME (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC) (Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)

38. GROSS MONTHLY INCOME (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")

Report total monthly income for your household. Identify the specific income recipient for each income source, yourself or another person in your household, as applicable. If you are the custodian filing for a child of the veteran, you must report your income and the child's income, if any.

SECTION IX: EXPECTED INCOME (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)

(Skip to Section XI if you are NOT claiming death pension benefits or parents DIC)

39. EXPECTED INCOME - NEXT 12 MONTHS (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "none")

Report expected total household 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 total household income for the 12 month period from the date you sign this application. Identify the specific income recipient for each income source, yourself or another person in your household, as applicable. If you are the custodian filing for a child of the veteran, you must report your expected income

and the child's expected income, if any.

SECTION X: MEDICAL, LAST ILLNESS, BURIAL, OR OTHER UNREIMBURSED EXPENSES (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)

(Skip to Section XI if you are NOT claiming death pension or parents DIC)

40. MEDICAL, LAST ILLNESS, BURIAL, OR OTHER UNREIMBURSED EXPENSES

Family medical expenses and certain other expenses actually paid by you may be deductible from your 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 educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are unreimbursed amounts paid by you for the veteran's or his/her child's last illness and burial and the 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.

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