Form VA Form 21-4171 VA Form 21-4171 Supporting Statement Regarding Marriage

OMB Control No. 2900-0115
Respondent Burden: 20 Minutes
VA DATE STAMP
(DO NOT WRITE IN THIS SPACE)

SUPPORTING STATEMENT REGARDING MARRIAGE
Privacy Act Notice: 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 38, Code of Federal Regulations 1.576 for routine uses (i.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 VA 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, published in the Federal Register. Your obligation to respond is voluntary. The requested information is
considered relevant and necessary to determine maximum benefits under the law. The responses you submit are
considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching
programs with other agencies.
Respondent Burden: We need this information to determine eligibility for benefits based on a marital relationship
between the claimant and the veteran (38 U.S.C. 101, 103, and 1102). Title 38, United States Code, allows us to ask
for this information. We estimate that you will need an average of 20 minutes to review the instructions, find the
information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB
control number is displayed. You are not required to respond to a collection of information if this number is not
displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.whitehouse.gov/omb/library/OMBINVC.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 and give your
comments or ask for mailing information on where to send your comments.
INSTRUCTIONS: Please complete all items. Your answer to every question is important to help us complete the claimant’s claim. If you do not know
the answer, write "unknown." For additional space, use Item 17, "Remarks," or attach a separate sheet, indicating the item number to which the answers
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN

2. FILE NUMBER

3. FIRST NAME - MIDDLE NAME - LAST NAME OF
CLAIMANT (SPOUSE OR SURVIVING SPOUSE)

C/CSS4B. ADDRESS OF PERSON COMPLETING THIS FORM

4A. NAME OF PERSON COMPLETING THIS FORM

I understand that this statement will be considered in connection with an application for VA benefits based on a marital relationship between the veteran
and the person named in Item 3.
5A. WHAT WAS/IS YOUR RELATIONSHIP
TO THE VETERAN? (Parent, child, brother,
sister, etc. If not related, state "None")

5B. WHAT WAS/IS YOUR RELATIONSHIP
TO THE CLAIMANT? (Parent, child,
brother, sister, etc. If not related,
state "None")

6A. HOW LONG HAD/HAVE
YOU KNOWN THE
VETERAN? (Months, years)

6B. HOW LONG HAD/HAVE
YOU KNOWN THE
CLAIMANT? (Months, years)

7A. HOW OFTEN HAD/HAVE YOU MET THE VETERAN?

7B. ON WHAT OCCASION(S) HAD/HAVE YOU MET THE VETERAN?

7C. HOW OFTEN HAVE YOU MET THE CLAIMANT?

7D. ON WHAT OCCASIONS HAVE YOU MET THE CLAIMANT?

8. WERE/ARE THE VETERAN AND THE CLAIMANT GENERALLY KNOWN AS
HUSBAND AND WIFE?

9. DID/DO EITHER THE VETERAN OR CLAIMANT EVER DENY THE MARRIAGE?

YES

YES

NO

10A. DID/DO YOU CONSIDER THE VETERAN AND THE CLAIMANT TO BE
HUSBAND AND WIFE?
YES

NO

NO

10B. FACT AND REASONS FOR SUCH BELIEF (If necessary use "REMARKS"
section on reverse and key answers to item number)

(If "Yes," complete Item 10B)

11. NAME(S) BY WHICH CLAIMANT WAS/IS KNOWN
FIRST NAME

LAST NAME

12A. HAD/HAVE YOU EVER HEARD THE VETERAN OR THE CLAIMANT REFER TO EACH OTHER AS HUSBAND AND WIFE?
YES

NO

(If "Yes," complete Items 12B and 12C)
12B. DATE

12C. PLACE

13A. DID/DO THE VETERAN AND THE CLAIMANT MAINTAIN A HOME AND LIVE TOGETHER AS HUSBAND AND WIFE?
YES

NO

(If "Yes," complete Item 13B)

13B. PERIODS OF TIME AND PLACES WHERE THE VETERAN AND THE CLAIMANT HAD/HAVE LIVED TOGETHER
BEGINNING DATE

VA FORM
NOV 2004

21-4171

ENDING DATE

CITY OR TOWN

EXISTING STOCKS OF VA FORM 21-4171, DEC 2001,
WILL BE USED.

STATE

14A. HAD/HAVE THE VETERAN AND THE CLAIMANT LIVED TOGETHER CONTINUOUSLY?
(If "Yes," complete Item 14B)
YES
NO
14B. EXPLANATION

15A. HAD/HAS THE VETERAN EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
YES

NO

(If "Yes," complete Item 15B)

15B. OTHER MARRIAGES OF VETERAN
TO WHOM MARRIED

DATE AND PLACE
OF MARRIAGE

TYPE OF MARRIAGE
(Ceremonial, etc.)

HOW MARRIAGE ENDED
(Death, divorce, etc.)

DATE AND PLACE
MARRIAGE ENDED

16A. HAS THE CLAIMANT EVER ENTERED INTO ANY OTHER MARRIAGE(S)?
YES

NO

(If "Yes," complete Item 16B)

16B. OTHER MARRIAGES OF CLAIMANT
TO WHOM MARRIED

DATE AND PLACE
OF MARRIAGE

TYPE OF MARRIAGE
(Ceremonial, etc.)

HOW MARRIAGE ENDED
(Death, divorce, etc.)

DATE AND PLACE
MARRIAGE ENDED

17. REMARKS

CERTIFICATION
I CERTIFY THAT the foregoing statements are true and correct to the best of my knowledge and belief.
18A. SIGNATURE

18B. DATE SIGNED

18C. DAYTIME TELEPHONE NUMBER (Including Area Code)

18D. EVENING TELEPHONE NUMBER (Including Area Code)

WITNESS TO SIGNATURE IF MADE BY "X" MARK
NOTE: Signature by mark must be witnessed by two persons to whom the signer is personally known and the signature and addresses of the witnesses
must be entered below.
19A. SIGNATURE OF WITNESS

19B. ADDRESS OF WITNESS

20A. SIGNATURE OF WITNESS

20B. ADDRESS OF WITNESS

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.