Va Form 21 6898 PDF Details

The VA Form 21-6898, known as the "Application for Amounts on Deposit for Deceased Veteran," serves a critical role in providing financial relief to families and dependents of deceased veterans. It is designed to ensure that amounts deposited by the Department of Veterans Affairs (VA) into the personal accounts of veterans during hospital treatment, institutional, or domiciliary care, and due at the time of their death, are distributed according to a specified order of preference. This form requires detailed information about the veteran, including their name and VA file number, as well as comprehensive data regarding the claimant such as their relationship to the deceased, addresses, and details concerning the veteran's last sickness and burial expenses. Moreover, the form encapsulates sections dedicated to dependency data, reimbursement waiver for unpaid creditors, and a strict certification process for all claimants. With an estimated respondent burden of 15 minutes, the form underscores the VA's commitment to privacy and the meticulous evaluation of claims to determine eligibility for benefits. Echoed within this document is an intricate balance of legal and procedural mandates designed to facilitate the posthumous financial management of veterans' affairs, reflecting a broader ethos of respect and support for those who have served their country.

QuestionAnswer
Form NameVa Form 21 6898
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesVBA 21 6898 ARE va form 21 6898 when to use

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OMB Control No. 2900-0133

Respondent Burden: 15 Mins.

APPLICATION FOR AMOUNTS ON DEPOSIT FOR DECEASED VETERAN

1. VETERAN'S NAME (First, Middle, Last - Print or type)

 

 

 

 

 

 

 

2. VA FILE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XC/XSS -

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. CLAIMANT'S NAME (First, Middle, Last - Print or type)

 

 

4. CLAIMANT'S ADDRESS (No., Street, City, Rural Route, State and ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. CLAIMANT'S DATE OF BIRTH

6. APPLYING (Check)

 

7. RELATIONSHIP OF CLAIMANT TO VETERAN (Check)

 

PAYER OR PERSON RESPON-

 

 

 

 

AS

 

 

FOR

 

 

 

SURVIVING

 

CHILD

 

 

MOTHER

 

FATHER

 

SIBLE FOR EXPENSES OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMANT

 

 

CLAIMANT

 

 

 

SPOUSE

 

 

 

 

 

LAST ILLNESS OR BURIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART I - TO BE COMPLETED BY OR ON BEHALF OF ALL CLAIMANTS

List below each living relative of the veteran in the order of preference down to and including all persons in the same class of relationship as that of the claimant. Write "None" when no surviving relative is in that class. If any of the information requested is unknown to you, write "Unknown" in the space.

8. RELATION-

NAME

ADDRESS

DATE OF BIRTH

NAME AND ADDRESS OF PERSON

SHIP TO

HAVING CUSTODY OF EACH MINOR

VETERAN

 

 

 

 

 

 

 

A.

 

 

 

 

SURVIVING

 

 

 

 

SPOUSE

 

 

 

 

 

 

 

 

 

B.MINOR AND ADULT CHILDREN

(If adopted, stepchild or illegitimate, state this fact below the name of the child)

C.FATHER

(State if Natural, Adoptive or Foster)

D.MOTHER

(State if Natural, Adoptive or Foster)

PART II - TO BE COMPLETED BY SURVIVING SPOUSE OR ON BEHALF OF DECEASED VETERAN'S CHILD OR CHILDREN

9.STATE NUMBER OF TIMES VETERAN HAS BEEN MARRIED, THEN COMPLETE ITEM 11A

10.STATE NUMBER OF TIMES SURVIVING SPOUSE HAS BEEN MARRIED, THEN COMPLETE ITEM 11B

 

 

 

MARRIED

 

 

MARRIAGE ENDED

HOW ENDED

11. MARITAL

 

 

 

 

 

 

 

 

 

 

 

PLACE

TO WHOM MARRIED

 

 

PLACE

(Death,

DATA FOR:

 

DATE

 

DATE

 

 

 

(City and State)

 

 

(City and State)

Divorce, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. VETERAN

B.

SURVIVING

SPOUSE OR

PARENT OF

CHILDREN

FOR WHOM

CLAIM IS

BEING MADE

VA FORM

21-6898

EXISTING STOCKS OF VA FORM 21-6898,

DEC 2001

 

NOV 1993, WILL BE USED.

PART III - DEPENDENCY DATA - TO BE COMPLETED BY THE VETERAN'S NATURAL, ADOPTIVE OR FOSTER PARENTS.

IF VETERAN WAS NOT SURVIVED BY A SURVIVING SPOUSE OR CHILD

12. WAS VETERAN AT ALL TIMES A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL CARE BEFORE REACHING 21 YEARS OF AGE?

 

YES

 

NO (If "No," explain fully, giving reason(s) and date parental control ended)

13.NET WORTH AT TIME OF VETERAN'S DEATH (Specific Instructions are on page 4)

A. STOCKS, BONDS, BANK DEPOSITS, ETC.

B. REAL ESTATE

C. OTHER PROPERTY

D. AMOUNT OF INDEBTEDNESS

E. NET WORTH

14. AVERAGE MONTHLY

15. INDICATE THE SOURCE FROM WHICH YOU RECEIVED YOUR MONTHLY INCOME AND THE AMOUNT FROM EACH

INCOME OF YOUR-

 

 

 

 

SOURCE OF INCOME

AMOUNT

SOURCE OF INCOME

AMOUNT

SELF AND SPOUSE

FROM ALL SOURCES

A.

 

D.

 

AT TIME OF

 

 

 

 

 

 

VETERAN'S DEATH

B.

 

E.

 

 

 

 

 

 

 

 

 

 

C.

 

F.

 

 

 

 

 

 

16. AVERAGE MONTHLY

17. INDICATE WHAT MONEY WAS PAID OUT FOR AND THE AMOUNT (Such as for housing, food, clothing, medical care, etc.)

EXPENSES OF

ITEM

AMOUNT

ITEM

AMOUNT

YOURSELF AND

SPOUSE AT TIME

A.

 

F.

 

OF VETERAN'S DEATH

 

 

 

B.

 

G.

 

 

 

 

 

 

 

C.

 

H.

 

 

 

 

 

 

 

D.

 

I.

 

 

 

 

 

 

 

E.

 

J.

 

 

 

 

 

 

18. WERE ANY PERSONS LIVING IN YOUR HOUSEHOLD DEPENDENT SOLELY UPON YOU FOR SUPPORT AT TIME OF VETERAN'S DEATH?

YES

NO (If "Yes," complete items below)

NAME OF DEPENDENT

DATE OF BIRTH

RELATIONSHIP TO CLAIMANT

PART IV - TO BE COMPLETED BY THE PAYER OR PERSON RESPONSIBLE FOR EXPENSES OF LAST SICKNESS OR.

BURIAL PROVIDED VETERAN WAS NOT SURVIVED BY SPOUSE, CHILD, OR DEPENDENT PARENT

19A. PLACE OF VETERAN'S DEATH (City and State)

19B. PLACE OF BURIAL (City and State)

19C. CLAIMANT'S RELATIONSHIP TO VETERAN

NOTE: ANSWER FULLY - Each charge entered below should be supported by a bill or statement of account from the person who rendered the service or who furnished the supplies and should show over his/her signature, the name of the deceased for whom the expense was incurred; whether the expense has been paid, and if so, by whom.

NATURE OF

NAME OF PERSON OR FIRM

AMOUNT OF

CHECK ONE

IF PAID, ENTER NAME OF PERSON OR

EXPENSE

RENDERING THIS SERVICE

EACH BILL

PAID

UNPAID

ESTATE WHOSE FUNDS WERE USED

 

 

 

 

PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOSPITAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NURSING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BURIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXPENSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXPENSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL EXPENSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. HAVE YOU BEEN REIMBURSED FROM ANY SOURCE FOR ANY OF THE EXPENSES PAID FROM YOUR PERSONAL FUNDS? (Check One)

YES

NO (If "Yes," specify amount and source)

VA FORM 21-6898, DEC 2001

PART IV (Continued) - REIMBURSEMENT WAIVER

NOTE: If any of the expenses are unpaid, this part should be signed by all unpaid creditors.

I CERTIFY THAT I hold the claimant responsible for payment of my portion of this benefit, and waive my right to collect from the Department of Veterans Affairs.

SIGNATURE OF CREDITOR

SIGNATURE OF CREDITOR

SIGNATURE OF CREDITOR

SIGNATURE OF CREDITOR

CLAIMANT'S CERTIFICATION (To be fully completed by or on behalf of all claimants)

I CERTIFY THAT the foregoing statements are true to the best of my knowledge and belief. If I am claiming reimbursement, I further certify that I paid or am responsible for the payment of the last sickness and burial expenses of the veteran and hereby make claim for any amounts due as reimbursement.

SIGNATURE OF CLAIMANT

SIGN

HERE

DATE SIGNED

REMARKS (Enter any additional information to items, identifying each by item number)

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.

VA FORM 21-6898, DEC 2001

READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM

LAWS GOVERNING PAYMENTS

PRIVACY ACT INFORMATION: The responses you submit are considered confidential, (38 U.S.C. 5701). They may be disclosed outside the Department of Veterans Affairs (VA) only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22, Compensation, Pension, Education and Rehabilitation Records - VA, published in the Federal Register. The requested information is considered relevant and necessary to determine maximum benefits provided under the law. Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB Control Number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your comments.

Section 5502(d) of 38 U.S.C., as amended, provides that gratuitous benefits deposited by the Department of Veterans Affairs into the Personal Funds of Patients for a veteran during hospital treatment, institutional or domiciliary care and due the veteran at the date of his/her death will be paid in the following order of preference:

(1)To the surviving spouse.

(2)If the veteran left no surviving spouse or the surviving spouse is dead at the time of settlement, then to the adult or minor children in equal parts. (A "child" includes illegitimate, adopted and stepchildren.)

(3)If no surviving spouse or child survives at the time of settlement, then to the dependent father and mother in equal parts, or all to the survivor. ("Father" and "Mother" includes persons other than natural parents who assumed the parental relationship to the veteran.)

(4)In all other cases, only so much of the benefit may be paid as may be necessary to reimburse a person who bore the expense of last sickness and burial of the veteran.

GENERAL INSTRUCTIONS

CLAIMANT'S CERTIFICATION: A separate claim must be filed on behalf of each minor or adult person for whom a share of the benefit is claimed.

All the information required in this application must be furnished and the questions must be answered fully. Answers must be written in a clear, legible hand, or typed. If any of the questions are not clear, and you want further information, write to VA for instructions. If you need more space to answer the questions, continue under "Remarks" or attach a sheet of paper and number the answers to correspond with the question on the application.

Existing law requires that claim for this benefit must be filed within five (5) years after the death of the veteran, or if any person so entitled is under legal disability at the time of the veteran's death, the five-year period shall run from the date of termination or removal of the legal disability.

Attach to this application certified statements and all other papers you are submitting in support of your claim. Write the veteran's name and claim number on each paper submitted. This is necessary for identification should they become separated from the application.

SPECIFIC INSTRUCTIONS

PROOF OF DEATH: Death of a veteran in a Government institution does not need to be proved by a claimant. Otherwise a certified copy of the public record of death should be furnished.

EVIDENCE ON FILE: If any of the evidence referred to has been previously filed in VA or is being filed by another claimant, it need not be filed in connection with this claim.

PROOF OF MARRIAGE: The marriage of a surviving spouse claiming benefit must be proved by furnishing a certified copy of the public or church record of marriage to the veteran and evidence of the dissolution of all prior marriages of the claimant and of the veteran, by furnishing a certified copy of the public record of death or decree of divorce from each former spouse.

PROOF OF RELATIONSHIP OF CHILD: If no surviving spouse survives, the age and relationship of each child claiming accrued pension or compensation should be proved by furnishing a copy of the public record of birth or a copy of the church record of baptism showing date of birth of each child and the names of the parents, certified over the signature of the custodian of such records.

PROOF OF RELATIONSHIP OF NATURAL OR ADOPTIVE MOTHER OR FATHER: A copy of the public record of birth or church record of baptism showing date of birth of the veteran and names of the parents and certified by the custodian of such records should be furnished. If neither of the records mentioned is obtainable, it is not necessary to establish one for the purpose of this claim. Instead you should submit the affidavit of the attending physician or midwife or the affidavits of two persons who have personal knowledge of the facts, showing the date of birth and the names of the parents and explaining the affiant's means of knowledge of the fact to which he or she testifies. If the veteran was an adopted child, a copy of the court order of adoption, certified by the custodian of the court record, should be furnished.

FOSTER MOTHER, OR FATHER OR STEPPARENTS (Person claiming to have stood in the relation of parent to the veteran): If the claimant is not the natural or adoptive parent of the veteran but was the last person who stood in the relation of parent to the veteran prior to his/her 21st birthday for a period of not less that one

(1)year prior to his/her entrance into the active military or naval service, the claimant will be required to execute VA Form 21-524, Statement of Person Claiming To Have Stood in Relation of Parent, which will be furnished upon receipt of this application.

NET WORTH

Item 13A: Include market value of corporate stocks, checking accounts, bank deposits, savings accounts, cash and currency.

Item 13B: Do not include the value of the single dwelling unit or that portion of real property used solely as your principal residence. On all other real estate reduce the market value by amount of the indebtedness thereon.

Item 13C: Report the total market value of your rights and interest in all other property not included in Items 13A and 13B. Do not include value of ordinary personal effects necessary for your daily living such as clothing and furniture.

Item 13D: Report all debts except mortgage(s) on real estate.

Item 13E: Report the total of Items 13A though 13C less 13D. This should be our nest net worth.

REIMBURSEMENT: If expenses of the veteran's or deceased beneficiary's last sickness and burial have not been paid, claim may be filed by the person who is responsible for the payment of these expenses, but THE REIMBURSEMENT WAIVER in Part IV of this form must be signed by all unpaid creditors. If such expenses have been paid, claim should be filed by the person or persons whose personal funds were used to pay such expenses. If the expenses were paid from funds of the deceased beneficiary's estate, claim should be filed by the executor or administrator thereof in which case there must also be submitted a copy of the letters of administration or letters testamentary certified over the signature and seal of the appointing court.

EVIDENCE IN SUPPORT OF REIMBURSEMENT CLAIM: The claim must be accompanied by statements of account (preferably on the printed billheads) of all creditors whose services were rendered in connection with the expense of last sickness and burial, of the veteran or deceased beneficiary. These statements must show the name of the deceased for whom the services were rendered, the nature and cost of the services rendered, all credits, and the name of the person from whom payment in whole or in part was received.

PAYMENT OF FEES: The payment of any fee in the preparation of this application is prohibited by law.

VA FORM 21-6898, DEC 2001

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This document requires particular information to be filled in, so ensure that you take some time to fill in exactly what is required:

1. Start completing the Va Form 21 6898 with a number of essential blanks. Consider all the information you need and be sure not a single thing neglected!

Filling in part 1 in Va Form 21 6898

2. Once your current task is complete, take the next step – fill out all of these fields - state this fact below the name of, C FATHER, State if Natural Adoptive or Foster, D MOTHER, State if Natural Adoptive or Foster, PART II TO BE COMPLETED BY, STATE NUMBER OF TIMES VETERAN HAS, STATE NUMBER OF TIMES SURVIVING, MARITAL DATA FOR, DATE, MARRIED, PLACE, City and State, TO WHOM MARRIED, and MARRIAGE ENDED with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Guidelines on how to fill out Va Form 21 6898 step 2

You can easily make errors when filling out the DATE, so be sure to look again before you'll finalize the form.

3. In this stage, check out BEING MADE, SURVIVING SPOUSE OR PARENT OF, CLAIM IS, VA FORM DEC, and EXISTING STOCKS OF VA FORM NOV. Each one of these will have to be filled in with highest accuracy.

Va Form 21 6898 conclusion process described (portion 3)

4. Now fill in this next part! Here you will have all these WAS VETERAN AT ALL TIMES A MEMBER, YES, If No explain fully giving reasons, A STOCKS BONDS BANK DEPOSITS ETC, B REAL ESTATE, C OTHER PROPERTY, D AMOUNT OF INDEBTEDNESS E NET, NET WORTH AT TIME OF VETERANS, AVERAGE MONTHLY INCOME OF YOUR, AVERAGE MONTHLY EXPENSES OF, INDICATE THE SOURCE FROM WHICH, SOURCE OF INCOME, AMOUNT, SOURCE OF INCOME, and AMOUNT fields to do.

Va Form 21 6898 conclusion process described (part 4)

5. When you near the completion of the document, you'll notice just a few more requirements that should be fulfilled. Particularly, WERE ANY PERSONS LIVING IN YOUR, YES, If Yes complete items below, NAME OF DEPENDENT, DATE OF BIRTH, RELATIONSHIP TO CLAIMANT, PART IV TO BE COMPLETED BY THE, BURIAL PROVIDED VETERAN WAS NOT, A PLACE OF VETERANS DEATH City and, B PLACE OF BURIAL City and State, C CLAIMANTS RELATIONSHIP TO VETERAN, NOTE ANSWER FULLY Each charge, NATURE OF, EXPENSE, and NAME OF PERSON OR FIRM RENDERING should all be filled out.

Writing section 5 in Va Form 21 6898

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