Form 29-541 Certificate Showing Residence and Heirs of Deceased Vete

OMB Control No. 2900-0469
Respondent Burden: 30 minutes
1. INSURANCE FILE NUMBER

CERTIFICATE SHOWING RESIDENCE AND HEIRS
OF DECEASED VETERAN OR BENEFICIARY

2. NAME OF INSURED (First, Middle, Last)

PRIVACY ACT INFORMATION: 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 identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S.
Government Life Insurance Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain this benefit.
RESPONDENT BURDEN: We need this information to determine your eligibility for a death benefit. Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 30 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/OMBINV.VA.EPA.html#VA. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.
3. THE QUESTIONS REFER TO THE ESTATE OF: 4A. ARE THERE HEIRS TO THIS ESTATE?

(Give first, middle, last name)

YES
NO
4B. HAS THERE BEEN OR WILL THERE BE A COURT-APPOINTED EXECUTOR OR
ADMINISTRATOR APPOINTED FOR THIS ESTATE?
YES

NO

(If "Yes," see note below. If "No," complete remaining items)

NOTE: If there has been or will be an executor or administrator appointed, furnish letters testamentary or letters of administration. Skip
the remaining items, sign on reverse, and return this form with your letters.
5. STATE OF RESIDENCE AT TIME OF DEATH (EXCLUDING MILITARY SERVICE)

IMPORTANT: Items 6 through 9 - Write the word "NONE" in each item where there is no next of kin. If any information is unknown
to the witnesses, the words "DO NOT KNOW" should be written in the space provided. If additional space is required, attach a
separate sheet. If separate sheets are necessary, each sheet must be signed.
6. SPOUSE OF DECEASED VETERAN/BENEFICIARY
A. NAME OF SPOUSE

B. AGE

D. DATE OF DEATH E. YEAR OF MARRIAGE

C. ADDRESS

(If deceased)

7. CHILD(REN) OF DECEASED VETERAN/BENEFICIARY
A. NAME(S) OF CHILD(REN)
(Include illegitimate, adopted
and unborn child(ren))

B. AGE

A. NAME OF PARENT

B. AGE

C. ADDRESS

D. DATE OF
DEATH
(If deceased)

8. PARENTS OF DECEASED VETERAN/BENEFICIARY
C. ADDRESS

E. PARENTS OF
CHILD(REN)

D. DATE OF DEATH (If deceased)

FATHER

MOTHER

IMPORTANT: If spouse, child(ren), or parent(s) survive the insured, skip to Item 11A on the reverse.
VA FORM
SEP 2006

29-541

EXISTING STOCKS OF VA FORM 29-541, FEB 2005,
WILL BE USED.

(Continued on Reverse)

9. BROTHER(S) AND SISTER(S) OF DECEASED VETERAN/BENEFICIARY
(STATE WHETHER FULL, HALF-BLOOD, OR ADOPTED)
A. NAME(S) OF BROTHER(S) AND
SISTER(S)

B. AGE

C. ADDRESS

D. DATE OF DEATH (If deceased)

NAME(S) OF CHILD(REN)
OF DECEASED BROTHER(S)
AND SISTER(S)

WE CERTIFY THAT to the best of our knowledge and belief, the above named are the only relatives of the veteran/beneficiary, living
or dead, and that the foregoing statements are true.
10. FIRST WITNESS INFORMATION

11. SECOND WITNESS INFORMATION

A. FIRST, MIDDLE, LAST NAME

A. FIRST, MIDDLE, LAST NAME

B. DAYTIME TELEPHONE NUMBER (Include Area Code)

B. DAYTIME TELEPHONE NUMBER (Include Area Code)

C. RELATIONSHIP TO DECEASED

C. RELATIONSHIP TO DECEASED

D. SIGNATURE

D. SIGNATURE

PENALTY: The statements contained herein are made with the full knowledge of the penalties imposed by law for making false
statements of a material fact.

QUESTIONS ABOUT THIS INSURANCE? CALL OUR TOLL-FREE NUMBER 1-800-669-8477.
VA Form 29-541, SEP 2006