Form 21-0538 Status of Dependents Questionnaire

Vi\. Department of

:,tJ Veterans Affairs

The compensation you receive for your service-connected disability includes an additional amount for
your spouse and/or child(ren). You are responsible for reporting any changes in the number of
your dependents.
To verify your continued entitlement to these additional benefits, you must complete and return the
form on the reverse side of this letter. If there is no change in the number of your dependents,
you will continue to receive your present rate. If the number of your dependents has changed, for
example, the loss or addition of a dependent, we will reduce or increase your payments accordingly.
If you do not complete and return the form to VA within 60 days from the date of this letter, we

will reduce your award by the amount of benefits you are receiving for your spouse and/or
child(ren).
After completing the form, please place it in the enclosed 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

VA FORM
MAR 2004

21-0538

o MB. Approved No. 2900-0500
Respondent Burden: 10m inutes

STATUS OF DEPENDENTS QUESTIONNAIRE
PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the
Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses (j .e., civil or criminal law enforcement, congressional communications,
epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest,
the administration of VA programs and delivery of V A benefits, verification of identity and status, and personnel administration) as identified in the VA
system of records, 58VA21/22 Compensation, Pension, Education, and Rehabilitation Records - VA, and published in the Federal Register. Your obligation
to respond is required to obtain or retain benefits. Giving. us your and your dependents SSN account information is mandatory. Applicants are required to
provide their SSN and the SSN of any dependents for whom benefits are claimed under Title 38 U.S.C. 5101 (c) (I). The VA will not deny an individual

benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January I, 1975,
and still in effect. Information that you furnish may be utilized in computer matching programs with other Federal or state agencies for the purpose of
determining your eligibility to receive VA Benefits, as well as to collect any amount owed to the United States by virtue of your participation in any
benefit program administered by the Department of Veterans Affairs.
IMPORTANT INFORMATION ABOUT INFORMATION COLLECTION: We need this information to determine continued eligibility for an additional
allowance for your spouse and/or child(ren) under 38 U.S.C. 1115. Title 38, United States Code, allows us to ask for this information. We estimate that
you will need an average of 10 minutes to review the instructions, find the information and complete this form. V A cannot conduct or sponsor a collection
of information unless a valid OMB control number is displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.whitehouse.gov!library!omb/OMBINVC.htmIHVA.If you desire, you can call 1-800-827-1000 to get information on where to send comments or suggestions
about this form.
1. FIRST - MIDDLE - LAST NAME OF VETERAN

3A. DATE OF MARR IAGE
(Mo., day, yr.)

2. ARE YOU MARRIED?

3B. PLACE OF MARR IAGE
(City, State)

(If "Yes," complete Item 3)
DYES IJNn'
3C. TO WHOM MARRIED? (First name, middle initial, last name)

3D. SOCIAL SECURITY NUMBER OF SPOUSE

NOTE -Please provide the following information for each child under age 18, over age 18 and under 23 and
attending school, or of any age if permanently disabled.
If you have more than four children, list the others in
Item 5, Remarks, giving the information requested in Items 4A, 4B, 4C, 4D,and 4E.
If you have no children
in any of the categories described above, write "None" in Item 4A.
4A. FULL NAME OF
EACH CHILD

~B. DATE OF BIRTH
(Mo., day, year}

4C. PLACE OF BIRTH
(City, State)

4D. SOCIAL
SECURITY NUMBER

4E. NAME AND ADDRESS OF PERSON HAVING
CUSTODY OF THE CHILD
(If child is not in the custody of person claiming
dependency allowance)
;

5. REMARKS
/

I HEREBY CERTIFY THAT the information I have given above is true and correct to the best of my knowledge
and belief.
6. TELEPHONE NUMBER(S) (Include Area Code)
A. DAYTIME

7A. SIGNATURE OF VETERAN OR GUARDIAN
I

I

B. EVENING
7B. DATE

SIGN HERE
IN INK
PENALTY - The law provid es 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.