VA Form 21P-601: Application for Accrued Amounts Due a Deceased Beneficiary

Fill in 1. VETERAN'S NAME (First, Middle Initial, Last), 2. VETERAN'S SOCIAL SECURITY NUMBER and 3. VETERAN'S FILE NUMBER.

Fill in 4. NAME OF DECEASED BENEFICIARY (If other than veteran - First, Middle Initial, Last).

Fill in 5. BENEFICIARY DATE OF DEATH (MM/DD/YYYY).

Fill in 6. CLAIMANT'S NAME (First, Middle Initial, Last).

Fill in 7. CLAIMANT'S SOCIAL SECURITY NUMBER and 8. CLAIMANT'S DATE OF BIRTH (MM/DD/YYYY).

Fill in 9. CLAIMAINT'S CURRENT MAILING ADDRESS (Number and street or rural route, P.O. Box, City, State, ZIP Code and Country).

Fill in 10. CLAIMANT'S TELEPHONE NUMBER (Include Area Code), 11. PREFERRED E-MAIL ADDRESS (If applicable) and 12. CLAIMANT'S RELATIONSHIP TO DECEASED BENEFICIARY.

In 13. Who are the deceased beneficiary's surviving relatives? check all that apply: SPOUSE, CHILD OR CHILDREN, PARENT or NONE. If NONE, skip to Question 14E.

List each person separately in Items 14A through 14D: the NAME (First, Middle Initial, Last), the RELATIONSHIP TO BENEFICIARY, the DATE OF BIRTH (MM/DD/YYYY) and the COMPLETE MAILING ADDRESS.

Definitions: Child means an unmarried child of the veteran who is under 18 years of age, or at least 18 but under 23 years of age and pursuing an approved course of education, or became incapable of self-support prior to reaching age 18. However, benefits may be payable to the veteran's children, regardless of age or marital status, if lump sum accrued benefits are payable.

Fill in 14E. WOULD YOU LIKE TO WAIVE SUBSTITUTION? Mark YES or NO. If YES, see Paragraph C of the Instructions.

The right to substitute may be waived by marking "Yes" in the designated box on this form. If the right to substitute is waived, VA may still consider the accrued claim; however, VA will do so based only on the evidence contained in the claims folder at the time of death. Accrued benefits are benefits that were due the beneficiary at the time of death but not paid prior to death.

Skip to Section V if you are claiming accrued benefits based on your relationship to the deceased beneficiary.

Complete this section only if you are claiming accrued benefits for reimbursement of expenses for last illness or burial.

The claim should be filed by the person or persons whose funds were or will be used to pay such expenses. If the expenses were paid from funds of the deceased beneficiary's estate, the claim should be filed by the executor or administrator of the estate. If the expenses have not been paid, the claim may be filed by the person who is responsible for the payment of these expenses.

List the expenses of last sickness and burial in Items 15A through 15E: the NAME OF PERSON OR FIRM, the NATURE OF EXPENSE (For example, physician, hospital, burial expenses, etc.) and the AMOUNT.

In 15D. CHECK ONE: UNPAID or PAID. In 15E. IF PAID, fill in the NAME OF PERSON OR ESTATE WHOSE FUNDS WERE USED.

In 16. Have you been reimbursed from any source for any of the expenses paid from your personal funds? mark YES or NO. If YES, specify the amount and source.

In 17. Did the beneficiary leave any other debts? mark YES or NO. If NO, skip to Item 19. If YES, fill in 18. LIST THE OTHER DEBTS IN ITEMS 18A AND 18B.

In 19. Has or will the beneficiary's estate be legally administered? mark YES or NO. If YES, attach a copy of the letters of administration or letters testamentary bearing the signature and seal of the appointing court.

If any of the expenses listed in Item 15D are unpaid, Section IV must be completed and signed by all unpaid creditors.

For each unpaid creditor, fill in 20A. NAME OF UNPAID CREDITOR OR FIRM, 20B. ADDRESS OF CREDITOR OR FIRM, 20C. SIGNATURE OF CREDITOR OR PERSON SIGNING FOR FIRM (Sign in ink), 20D. TITLE and 20E. DATE SIGNED (MM/DD/YYYY).

I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.

Sign in ink on 23A. SIGNATURE OF CLAIMANT and enter TODAY'S DATE (MM/DD/YYYY) in 23B.

If you sign with an "X," then you must have two people witness you as you sign. They must sign the form and print their names and addresses.

Exception: A claim for lump sum accrued benefits (benefits that were withheld from a competent veteran during hospital treatment, institutional, or domiciliary care) must be filed within five years from the veteran's date of death.

However, if the person who is entitled to the lump sum accrued benefits has been declared incompetent by a court of law or Federal or State government agency at the time of the veteran's death, the five-year period begins from the date of termination or removal of the finding of incompetency.

A claim for accrued benefits must be filed within one year from the date of death of the deceased beneficiary.

When you have completed this application mail to: Department of Veterans Affairs, Pension Intake Center, P.O. Box 5365, Janesville, WI 53547-5365 or take it to the nearest VA regional office.

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 (18 U.S.C. §§ 1001-1002).

Do not complete this form if you have applied for Survivor Benefits by using VA Form 21P-534EZ or 21P-535.