Form 21-0538 Status of Dependents Questionnaire

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
APR 2009

21-0538

OMB. Approved No. 2900-0500
Respondent Burden: 10 minutes

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 (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, 58VA21/22/28 Compensation,
Pension, Education, and Vocational Rehabilitation and Employment 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) (1). 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 1, 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.
RESPONDENT BURDEN: 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. VA 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/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.
1. FIRST - MIDDLE - LAST NAME OF VETERAN

3A. DATE OF MARRIAGE
(Mo., day, yr.)

3B. PLACE OF MARRIAGE
(City, State)

2. ARE YOU MARRIED?

(If "Yes," complete Items 3A-3E )
YES
NO
3C. TO WHOM MARRIED? (First name, middle initial, last name)

3D. SOCIAL SECURITY NUMBER OF SPOUSE

3E. DATE OF BIRTH OF SPOUSE (Mo., day, year)

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

4B. 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

B. EVENING

7A. SIGNATURE OF VETERAN OR GUARDIAN

SIGN HERE
IN INK
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.

7B. DATE