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

In 1A, enter the veteran's name (First, Middle Initial, Last).

In 1B, enter the veteran's Social Security number, and in 1C the veteran's date of birth (MM/DD/YYYY).

In 1D, mark YES or NO: Has the veteran, surviving spouse, child, or parent ever filed a claim with VA?

In 1E, enter the VA file number (If known).

In 1F, mark YES or NO: Did the veteran die while on active duty? In 1G, enter the veteran's service number.

In 1H, enter the veteran's date of death (MM/DD/YYYY).

In 2A, enter the claimant's name, your name (First, Middle Initial, Last).

In 2B, check one relationship to the veteran: surviving spouse, child 18-23 in school, custodian filing for child under 18, or disabled adult child.

In 2C, enter your Social Security number; in 2D, your date of birth (MM/DD/YYYY); in 2E, mark YES or NO: Are you a veteran?

In 2F, enter your mailing address: number and street or rural route, P.O. Box, City, State, ZIP Code and Country.

In 2G, enter your telephone number (Include Area Code); in 2H, the e-mail address is optional.

In 2I, check all that apply: Dependency and Indemnity Compensation (D.I.C.), Survivors Pension, Accrued Benefits.

Skip to Section IV if the veteran was receiving VA compensation or pension benefits at the time of their death.

In 3A, mark YES or NO: Did the veteran serve under another name? If YES, list other names the veteran served under (First, Middle Initial, Last).

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 in Section XI.

In 11A, enter the name of the financial institution, the bank where you want your direct deposit.

In 11B, enter the routing or transit number: the first nine numbers located at the bottom left of your check.

In 11C, check the appropriate box and provide the account number, or simply write "Established," if you have a direct deposit with VA.

In 12A, the claimant's signature or mark with an "X" if unable to sign is required; in 12B, enter the date signed (MM/DD/YYYY).

By signing, you certify that the statements in this document are true and complete to the best of your knowledge.

Two (2) witness signatures are required only if Item 12A is signed with an "X".

In 13A, the witness signs in ink only if the claimant signed in Item 12A using an "X", and 13B and 13C ask for the printed name and address of the first witness.

In 13D, the second witness signs in ink only if the claimant signed in Item 12A using an "X", and 13E and 13F ask for the printed name and address of the second witness.

Complete Section IV only if claiming benefits as the surviving spouse of the veteran; skip to Section VI if you are NOT claiming benefits as the surviving spouse of the veteran.

When reporting place, if the country is the United States, VA needs city and state as well.

In 4B, mark YES or NO: Were you married to the veteran at the time of his/her death? If NO, complete Item 4C.

In 4N, mark YES or NO: Have you remarried since the death of the veteran? If NO, skip to Item 5A.

Complete Section VI only if claiming benefits for a child(ren) of the veteran; skip to Section VII if you are NOT claiming benefits for a child(ren) of the veteran.

In most circumstances, children over the age of 23 are not considered dependent for VA purposes, unless the child is determined to be seriously disabled based on a condition that started before turning 18.

Skip Section IX, Income and Assets, to Section X if you are NOT claiming survivors pension but claiming any last expenses.

Assets are all the money and property you or your dependents own.

In 9A, mark YES or NO: Do you or your dependents have over $75,000.00 in assets (not including the value of your primary residence)? If YES, please submit VA Form 21P-0969 (checked October 31, 2026).

Section XIV, Alternate Signer Certification and Signature, is required only if Item 12B is blank.

Examples of evidence which VA may request include: durable power of attorney showing the name and signature of the claimant and your authority as attorney in fact or agent; affidavit or notarized statement from an institution or person responsible for the care of the claimant indicating the capacity or responsibility of care provided.

I understand that I may be asked to confirm the truthfulness of the answers to the best of my knowledge under penalty of perjury.

If you are not ready to submit a claim for D.I.C., Survivors Pension, and/or Accrued Benefits, please complete a VA Form 21-0966, Intent to File a Claim for Compensation and/or Pension, or Survivors Pension and/or D.I.C., to protect your date of claim. If you complete the VA Form 21P-534EZ within one year of filing the VA Form 21-0966, your completed application will be considered filed as of the date of receipt of the VA Form 21-0966.

Use this form to submit a claim for D.I.C., Survivors Pension, and/or Accrued Benefits.

Submit simultaneously with your claim a copy of the veteran's death certificate (unless the veteran died on active duty).

Submit simultaneously with your claim all necessary income and asset information.

If submitting by mail, send completed form to: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365.