Form 21-0537 Marital Status Questionnaire

You are receiving dependency and indemnity compensation (DIC) as the surviving spouse of a veteran
who died in service or from service-connected causes. Generally, a surviving spouse’s entitlement to
DIC ends with remarriage. If a surviving spouse remarries, entitlement may continue provided the
marriage began after age 57 or has been terminated. You are responsible for reporting any change in
your marital status.
We need to verify your marital status. Please answer the questions below.
If you do not return this letter with your answers to VA within 60 days of the date shown above, we
will stop your DIC benefits. After answering the questions below, please return this letter in the
enclosed envelope. Be sure to place it in the envelope so that the return address of the regional office
shows through the envelope window.
You have the right at any time to submit additional information or to have a personal hearing to explain
or clarify your statements. You also have the right to be represented at the hearing by a representative
of your choice.
Sincerely yours,

Veterans Service Center Manager
Enclosure

OMB Approved No. 2900-0495
Respondent Burden: 5 minutes

MARITAL STATUS QUESTIONNAIRE
PRIVACY ACT INFORMATION: Payment of death benefits cannot be made unless the information requested is furnished as required by existing law (38 U.S.C. 101(3)). The
responses you submit are considered confidential, (38 U.S.C. 5701). They may disclosed outside the Department of Veterans Affairs only if the disclosure is authorized by
the Privacy Act, including the routine uses identified in the 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 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 display a valid OMB Control
Number. Public reporting burden for this collection of information is estimated to average 5 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.

1A. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?

1B. DATE OF MARRIAGE

NO (If "Yes," please provide the date in Item 1B and the name of your spouse in Item 1C)
YES
1C. NAME OF SPOUSE

2A. HAS YOUR REMARRIAGE BEEN TERMINATED?
NO (If "Yes," please provide the date in Item 2B and the reason for termination (i.e., death, divorce) in Item 2C)
YES
2B. DATE OF TERMINATION
2C. REASON FOR TERMINATION

3A. DAY TIME TELEPHONE (Include Area Code)

4A. SIGNATURE

VA FORM
JAN 2004

3B. EVENING TELEPHONE NUMBER (Include Area Code)

4B. DATE SIGNED

21-0537