Old Version of SSA-24

SSA-24 old version.pdf

Application for Survivor's Benefits

Old Version of SSA-24

OMB: 0960-0062

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GENERAL INSTRUCTIONS
FOR APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION, DEATH PENSION AND ACCRUED
BENEFITS BY A SURVIVING SPOUSE OR CHILD (INCLUDING DEATH COMPENSATION IF APPLICABLE)
VA FORM 21-534
Note: Read very carefully, detach, and keep these instructions for your reference.

A. How can I contact VA if I have questions?

2. Death pension may be payable when:

If you have any questions about this form, how to fill it
out, or about VA benefits, contact your nearest VA
regional office. You can locate the address of the nearest
regional office in your telephone book blue pages under
"United States Government, Veterans" or call 1-800-8271000 (Hearing Impaired TDD line 1-800-829-4833). You
may also contact VA by Internet at
http://www.vba.va.gov/benefits/address.htm.
B. What is the purpose of VA Form 21-534?

VA benefits you may be entitled to receive as a
surviving spouse or child of a deceased veteran, and
any money VA owes the veteran but did not pay
prior to his/her death (accrued benefits).
If you apply for any one of these benefits, the law requires
that we also consider you for the others.
C. What is the purpose of the attached SSA-24 form?
You can apply for Social Security (SS) benefits by using
the SSA-24 form attached to this VA Form (see pages 9
and 10). You don't have to apply if you don't want to or
have already done so. If you do want to apply, fill it out
and leave it attached. We will send it to the Social
Security Administration for you. They will then contact
you.
D. What are dependency and indemnity compensation
(DIC) and death pension benefits, and how does VA
decide what I will or will not receive?
1. Dependency and indemnity compensation may be
payable when:
a veteran's death occurred in service, or
a veteran dies of a service-connected disability, or
in certain circumstances if a veteran rated totally
disabled from service-connected disability dies
from non-service-connected conditions.
Unless a claim for dependency and indemnity compensation
is filed within one year from the date of the veteran's death,
that benefit is not payable from a date earlier than the date
the claim is received in the VA.

21-534

VA pays pension based on the amount of family income
and the number of dependent children. This is based on
law. VA must include as income all sources that Federal
law specifies. If there is no surviving spouse, pension may
be payable on behalf of a child or children.
Unless a claim for pension is filed within 45 days from the
date of the veteran's death, that benefit is not payable from a
date earlier than the date the claim is received in the VA.

Use VA Form 21-534 to apply for:

VA FORM
JUN 2004

the death of a veteran with wartime service is not
due to service, and
income is within applicable limits.

If it is determined that you are entitled to DIC and death
pension, we will pay you whichever benefit entitles you to
the most money. Benefit rates and income limits are
frequently changed, so it is not possible to keep this
information current in these instructions. You can find out
what the current income limitations and rates of benefits
are by contacting your nearest VA regional office.
E. How do I apply for aid and attendance allowance
and/or housebound benefits?
VA may pay a higher rate of DIC or pension to a
surviving spouse who is blind, a patient in a nursing home,
otherwise needs regular aid and attendance, or who is
permanently confined to his or her home because of a
disability. If you wish to apply for this benefit, check
"Yes" for Item 31.
F. How do I complete my application?
Print all answers clearly. If an answer is "none" or "0,"
write that. Your answer to every question is important to
help us complete your claim. If you do not know the
answer, write "unknown." For additional space, use Item
48, "Remarks, " or attach a separate sheet, indicating the
item number to which the answers apply. Make sure you
sign and date this application (Items 44 and 45).
Note: If the claim is being made on behalf of a minor or
incompetent person, the application form should be
completed and filed by the legal guardian. If no legal
guardian has been appointed, it may be completed and
filed by some person acting on behalf of the minor or
incompetent person.

EXISTING STOCKS OF VA FORM 21-534,
JUNE 1998, WILL BE USED.

General Instructions

Page 1

G. What do I do when I have completed my
application?
When you have completed this application mail it or take
it to a VA regional office. Be sure to attach any materials
that support and explain your claim. Also, make a
photocopy of your application and everything that you
submit to VA before mailing it.

VA Form 21-22, Appointment of Veterans Service
Organization as Claimant’s Representative, or VA Form
22A, Appointment of Individual as Claimant’s
Representative. You may also download these forms
at http://www.va.gov/vaforms/. If you have already
designated a representative, no further action is required
on your part.

H. How can I assign someone to act as my
representative?

I. What if I believe that VA has made an error
in processing or deciding my benefits?

A representative can be an accredited member of an
accredited organization or other service organization that
the Secretary of Veterans Affairs recognizes, an agent
recognized by VA, or a licensed lawyer. Agents and
attorneys can charge you for services that you get from
them only after the Board of Veterans’ Appeals (BVA)
gives you their final decision about your application. That
means you can use an attorney during any stage of your
application for benefits. However, the agent or attorney
cannot charge you for services unless you are trying to
resolve a dispute with VA after BVA has made a decision
about your claim.

You can ask for a personal hearing at any time during the
processing of your claim. That means you can ask for the
hearing while VA is processing your claim or after VA
has made a decision. You should contact the nearest VA
office and tell them that you want a personal hearing on
your case. Someone in the local VA office will arrange a
time and a place for your hearing. At this hearing, you can
bring witnesses. VA will record whatever you and your
witnesses say during the hearing and include it in the
official record. VA will furnish the hearing room and
officials, and prepare a transcript of the hearing. VA
cannot pay your expenses or the expenses of anyone you
want to bring with you to the hearing.

If you want to use a representative to help you with your
application, contact the nearest VA office. Depending on
the type of representative you want to designate, we will
send you one of the following forms:

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 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, and published in the Federal
Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is
mandatory. Applicants are required to provide their SSN under Title 38 USC 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. 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 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 eligibility for death benefits and accrued benefits under 38
U.S.C. 1310 through 1314, 1532 through 1543, and 5121. Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 75 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/library/omb/OMBINVC.html#VA. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

General Instructions

Page 2

OMB Approved No. 2900-0004
Respondent Burden: 1 hour 15 minutes
(DO NOT WRITE IN THIS SPACE)

Application for Dependency and Indemnity Compensation, Death Pension and Accrued
Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable)
VA Form 21-534
Please read the attached "General Instructions" before you fill out this form.
1. Did the veteran ever file a claim with VA?
2. What is the VA file number?
SECTION

Yes

Tell us what you
are applying for
and what you and
the deceased
veteran have
applied for

(If "Yes," answer Item 2)

3. Has the surviving spouse or child ever filed
a claim with VA?
Yes

4. What is the VA file number?

(If "Yes," answer Items 4
through 6)

5. What is the name of the person on whose service the claim was filed?
First
Middle
6. What is your relationship to that person?

Last

7. Are you claiming service connection for cause of death?
Yes

SECTION
II
Tell us
about you
and the
deceased
veteran

8. What is the veteran's name?
First

Middle
9. What is the veteran's Social Security number?

Last

Suffix (If applicable)

10a. Did the veteran serve under another name?
Yes
No
(If "Yes," answer Items 10b)

10b. Please list the other name(s) the veteran
served under:

11. What is the veteran's date of birth?

mo day
Attach a copy of the
death certificate
unless the veteran
died in active service
of the Army, Navy,
Air Force, Marine
Corps, or Coast
Guard, or in a U.S.
government
institution.

13. Was the veteran a former prisoner of war?

12. What is the veteran's date of death?

Yes
mo day

14. What is your name? (First, Middle, Last Name)

15. What is your relationship to the veteran?
(check one)
Surviving Spouse

Child

16. What is your address?
Street address, Rural Route, or P.O. Box
City
17. What are your telephone numbers?
(Include Area Code)

Apt. number
State

Country
ZIP Code
18. What is your e-mail address?

Daytime
Evening
19. What is your Social Security number?

20. What is your date of birth?
mo day

VA FORM
JUN 2004

21-534

EXISTING STOCKS OF VA FORM 21-534, JUNE 1998,
WILL BE USED

yr
21-534

page 1

SECTION Tell us about
the veteran's
III
active duty
service
1. Enter complete information for
all periods of service. If more
space is needed use Item 48
"Remarks."
2. If the veteran never filed a
claim with VA, attach the original
DD214 or a certified copy for
each period of service listed. We
will return original documents to
you.

Note: Skip to Section IV if the veteran was receiving VA compensation or pension at the
time of his/her death.
21a. Entered Active
Service (first period)
mo day

Attach a copy of your marriage
certificate showing your marriage
to the veteran.

21f. Branch of Service

21h. Entered Active
21i. Place
Service (second period)
mo day

mo day

veteran's
marital history

21e. Place

21g. Grade, Rank,
or Rating

yr
21j. Service Number

21k. Left This Active
Service

SECTION Tell us about
IV
your and the

21c. Service Number

21d. Left This Active
Service
mo day

21b. Place

21l. Place

21m. Branch of Service

21n. Grade, Rank,
or Rating

Note: Skip to Section V if the veteran was receiving additional VA benefits for you as his/her
spouse at the time of his/her death unless you remarried after the veteran's death.
You must furnish complete information about all marriages of the surviving spouse and the
veteran. If you need additional space, please attach a separate sheet of paper providing the
requested information about the marriages.

The veteran's marriages
22a. How many times was the veteran married?
22b. Date of
Marriage

22e. Date marriage 22f. Place
ended

22c. Place

22d. To whom
married

(city/state or country)

(first, middle initial, last
name)

22g. How marriage
ended

(city/state or country)

mo day yr

(death, divorce)

The surviving spouse's marriages. Note: Items 23a through 27 should be completed by the veteran's surviving
spouse. If the claimant is not the surviving spouse, skip to Section V.
23a. How many times were you married?
23c. Date of
Marriage

23b. Have you remarried since the death of the veteran?

23d. Place

23e. To whom
married

(city/state or country)

(first, middle initial, last
name)

23f. Date marriage 23g. Place
ended

mo day yr

23h. How marriage
ended

(city/state or country)

mo day yr

Yes

(death, divorce)

21-534

page 2

SECTION IV Tell us about your and the veteran's marital history (continued)
24. Was a child born to you and the veteran
during your marriage or prior to your
marriage?

Answer Item 24 only if you
were married to the veteran
for less than one year.

Yes

26. Did you live continuously with the
veteran from the date of marriage to the
date of his/her death?
Yes

25. Are you expecting the birth of a child of
the veteran?
Yes

27. What was the cause of the separation?
Give the reason, date(s), and duration of the
separation. If the separation was by court order,
attach a copy of the order.

(If "No", answer Item 27)

SECTION Tell us about
the
V
unmarried
children of the
veteran

Note: You should provide a
copy of the public record of
birth or a copy of the court
record of adoption for each
child listed in Item 28a unless
the veteran was receiving
additional VA benefits for the
child.

28a. Name of child
(First, middle initial,
Last)

Note: Skip to Section VI if you are not claiming benefits for any children that meet
the following criteria.
VA recognizes the veteran's biological children, adopted children, and stepchildren as
dependents. These children must be unmarried and:
under age 18, or
between 18 and 23 and pursuing an approved course of education, or
of any age if they became permanently unable to support themselves before
reaching age 18.
"Seriously disabled" (Item 29e) means that the child became permanently unable to support
himself/herself before reaching age 18. Furnish a statement from an attending physician or
other medical evidence which shows the nature and extent of the physical or mental
impairment.
If you need additional space, please attach a separate sheet of paper providing the
requested information about each child.

28b. Date and place
of birth (City/State
or Country)

mo day

28c. Social Security 29a.
29b.
29c.
29f. Child
29d. 18 - 29e.
Number
Biological Adopted Stepchild 23 yrs old Seriously previously
disabled married
and in
school

21-534

page 3

SECTION V Tell us about the unmarried children of the veteran (continued)
Tell us about the children listed above that don't live with you.
30a. Name of child
(first, middle initial, last)

30b. Child's Complete Address

30c. Name of person the child 30d. Monthly amount you
lives with (if applicable)
contribute to child's
support

$
$
$

SECTION Tell us if you
VI
are
housebound,
in a nursing
home or
require aid
and
attendance
If you answered "yes" to Item
31 and are not in a nursing
home, submit a statement
from your doctor showing the
extent of your disabilities. If
you are in a nursing home,
attach a statement signed by
an official of the nursing home
showing the date you were
admitted to the nursing home,
the level of care you receive,
the amount you pay
out-of-pocket for your care,
and whether Medicaid covers
all or part of your nursing
home costs.

31. Are you claiming aid and attendance
allowance and/or housebound benefits
because you need the regular assistance of
another person, are having severe visual
problems, or are housebound?
Yes

(If "No," skip to section VII)

32b. What is the name and complete mailing
address of the facility?

32a. Are you now in a nursing home?

Yes

(If "Yes," answer Items 32b and 32c also)

32c. Does Medicaid cover all or part of your
nursing home costs?

Yes

(If "No," answer Item 32d also)

32d. Have you applied for Medicaid?
Yes

21-534

page 4

SECTION Tell us the net
VII
worth of you and
your dependents
Note: If you are filing this
application on behalf of a minor or
incompetent child of the veteran and
you are the child's custodian, you
must report your net worth as well as
the net worth of the child for whom
benefits are claimed.

Source

VA cannot pay you pension if your net worth is sizeable. Net worth is the market value of
all interest and rights you have in any kind of property less any mortgages or other claims
against the property. However, net worth does not include the house you live in or a
reasonable area of land it sits on. Net worth also does not include the value of personal
things you use everyday like your vehicle, clothing, and furniture. You must report net
worth for yourself and all persons for whom you are claiming benefits.
For Items 33a through 33f, provide the amounts. If none, write "0" or "None."

Surviving spouse or
Custodian of children

Name:

Child(ren)
Name:

Name:

(first, middle initial, last)

33a. Cash, bank accounts,
certificates of deposit (CDs)
33b. IRAs, Keogh Plans, etc.
33c. Stocks, bonds, mutual funds
33d. Value of business assets
33e. Real property (not your home)
33f. All other property

SECTION Tell us about the
VIII
income of you and
your dependents
Payments from any source will
be counted, unless the law says
that they don't need to be
counted. Report all income, and
VA will determine any amount
that does not count.
Note: If you are filing this
application on behalf of a minor
of whom you are the custodian,
you must report your income as
well as the income of each child
for whom benefits are claimed.

Report the total amounts before you take out deductions for taxes, insurance, etc.
Do not report the same information in both tables.
If you expect to receive a payment, but you don't know how much it will be, write
"Unknown" in the space.
If you do not receive any payments from one of the sources that we list, write "0" or
"None" in the space.
If you are receiving monthly benefits, give us a copy of your most recent award letter.
This will help us determine the amount of benefits you should be paid.
34a. Have you claimed or are you receiving
34b. Is Social Security based on your own
benefits from the Social Security
employment?
Administration on your own behalf or on
behalf of child(ren) in your custody?
Yes
No
(If "Yes," answer item 34b)
35. Has a surviving spouse or child filed a
claim for compensation from the Office
of Worker's Compensation Programs
based on the death of the veteran?
Yes

Yes

36. Has a court awarded damages based on
the death of the veteran or is a claim or
legal action for damages pending?
Yes

37. Have you claimed or are you receiving Survivor Benefit Plan (SBP) annuity from a
service department based on the death of the veteran?
Yes

No
21-534

Page 5

SECTION VIII

Tell us about the income of you and your dependents (continued)

Monthly Income - Tell us the income you and your dependents receive every month

Sources of recurring monthly
income

Surviving spouse or
Custodian of children

Name:

Child(ren)
Name:

Name:

(first, middle initial, last)

38a. Social Security
38b. U.S. Civil Service
38c. U.S. Railroad Retirement
38d. Military Retirement
38e. Black Lung Benefits
38f. Supplemental Security Income
(SSI)/ Public Assistance
38g. Other income received monthly
(Please write source below:)

Expected income next 12 months - Tell us about other income for you and your dependents
Report expected income for the 12 month period following the veteran's death. If the claim is filed more than 45 days after the veteran
died, report the expected income for the 12 month period from the date you sign this application.

Sources of income
for the next 12
months

Surviving spouse or
Custodian of children

Name:

Child(ren)
Name:

Name:

(first, middle initial, last)

39a. Gross wages and salary
39b. Total dividends and interest
39c. Life insurance
39d. Other income expected
(Please write source below:)

21-534

Page 6

SECTION IX
Tell us about medical,
last illness, burial or
other unreimbursed
expenses

40a. Amount paid by
you

Family medical expenses and certain other expenses actually paid by you may be deductible from your
income. Show the amount of any continuing family medical expenses such as the monthly Medicare
deduction or nursing home costs you pay. Also, show unreimbursed last illness and burial expenses
and educational or vocational rehabilitation expenses you paid. Last illness and burial expenses are
unreimbursed amounts paid by you for the veteran's or his/her child's last illness and burial and the
veteran's just debts. Educational or vocational rehabilitation expenses are amounts paid for courses of
education, including tuition, fees, and materials. Do not include any expenses for which you were
reimbursed. If you receive reimbursement after you have filed this claim, promptly advise the VA
office handling your claim. If more space is needed attach a separate sheet.

40b. Date Paid

40c. Purpose
(Medicare deduction,
nursing home costs,
burial expenses, etc.)

40d. Paid to
(Name of nursing home,
hospital, funeral home,
etc.)

40e. Relationship of person for
whom expenses paid

$
mo day

mo day

SECTION
X
Give us direct
deposit information
If benefits are
awarded we will need more
information in order to
process any payments to
you. Please read the
paragraph starting with,
"All Federal payments..."
and then either:
1. Attach a voided
check, or
2. Answer questions
41-43 to the right.

All Federal payments beginning January 2, 1999, must be made by electronic funds transfer (EFT) also
called Direct Deposit. Please attach a voided personal check or deposit slip or provide the information
requested below in Items 41, 42, and 43 to enroll in Direct Deposit. If you do not have a bank account
we will give you a waiver from Direct Deposit, just check the box below in Item 41. The Treasury
Department is working on making bank accounts available to you. Once these accounts are available,
you will be able to decide whether you wish to sign-up for one of the accounts or continue to receive a
paper check. You can also request a waiver if you have other circumstances that you feel would cause
you a hardship to be enrolled in Direct Deposit. You can write to: Department of Veterans Affairs, 125
S. Main Street Suite B, Muskogee OK 74401-7004, and give us a brief description of why you do not
wish to participate in Direct Deposit.
41. Account number (Please check the appropriate box and provide that account number, if applicable)
I certify that I do not have an account with a financial
Checking
institution or certified payment agent
Savings
Account number
42. Name of financial institution

43. Routing or transit number

21-534

Page 7

SECTION Give us
XI
your
signature
1. Read the box that starts,
"I certify and authorize
the release of
information:"

I certify and authorize the release of information:
I certify that the statements in this document are true and complete to the best of my knowledge. I
authorize any person or entity, including but not limited to any organization, service provider,
employer, or government agency, to give the Department of Veterans Affairs any information about
me except protected health information, and I waive any privilege which makes the information
confidential.
45. Today's date

44. Your signature

2. Sign the box that
says, "Your signature."
3. If you sign with an "X,"
then you must have 2
people you know
witness you as you sign.
They must then sign the
form and print their
names and addresses
also.

SECTION
XII

mo day yr
46a. Signature of witness (If claimant
signed above using an "X")

46b.

Printed name and address of witness

47a. Signature of witness (If claimant
signed above using an "X")

47b.

Printed name and address of witness

48. Remarks (If you need more space to answer a question or have a comment about a specific item
number on this form please identify your answer or statement by the part and item number)

Remarks - Use this
space for any
additional
statements
that you would like
to make concerning
your application.

IMPORTANT
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 which you
are not entitled to.

21-534

Page 8

Form Approved
OMB Approved No. 0960-0062
SOCIAL SECURITY ADMINISTRATION

APPLICATION FOR SURVIVORS BENEFITS

(DO NOT WRITE IN THIS SPACE)

(PAYABLE UNDER TITLE II OF THE SOCIAL SECURITY ACT)
IMPORTANT-- Read instructions before completing form. Detach and retain ONLY the instruction sheet

VA DATE STAMP

1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

2. DATE OF DEATH

NOTE: If the veteran's Social Security No. is unknown, complete Items 4, 5, 6 and 7 about veteran.
4. DATE OF BIRTH

3. SOCIAL SECURITY NO. OF VETERAN

6. NAME OF FATHER

5. PLACE OF BIRTH

8. DID THE VETERAN WORK IN THE RAILROAD
INDUSTRY AT ANY TIME AFTER 1936?

7. MAIDEN NAME OF MOTHER

YES

NOTE: The following information should be furnished for each period of the veteran's active service (regular or reserves) after September 7, 1939, in the
military service of the United States or service as a commissioned officer in the Public Health Service or the National Oceanic and Atmospheric
Administration or during WWII, Philippine or Filipino or Allied country military service. If additional space is needed, attach a separate sheet.
9A. DATE ENTERED ACTIVE SERVICE

9B. SERVICE NO.

10. RELATIONSHIP OF APPLICANT TO VETERAN
SURVIVING SPOUSE

CHILD

9C. DATE SEPARATED FROM ACTIVE
SERVICE

11. DATE OF BIRTH OF APPLICANT

9D. GRADE, RANK, OR RATING, ORGANIZATION
AND BRANCH OF SERVICE

12. VA FILE NO.

PARENT

CHILDREN: Show names of surviving children (including natural children, adopted children and stepchildren) or dependent grandchildren (including
stepgrandchildren) who at any time since the veteran died, were unmarried and (a) under age 18; (b) age 18 to 19 and attending secondary school; (c)
disabled or handicapped (18 or over and disability began before age 22).
13A.

13B.

13C.

13D.

I know that anyone who makes or causes to be made a false statement or representation of a material fact in an application or for use in determining a
right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. I affirm that all information I
have given in this document is true.
14. DATE (Month, day, year)

15. SIGNATURE OF APPLICANT (First name, middle initial, last name) (Sign in ink)
SIGN
HERE

16. MAILING ADDRESS OF APPLICANT (No. and street or rural route, city or P.O., State and ZIP Code)

17. TELEPHONE NO. (Include Area Code)

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE BY "X" MARK ABOVE
18A. SIGNATURE OF WITNESS

18B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

19A. SIGNATURE OF WITNESS

19B. ADDRESS OF WITNESS (No. and street, city, State and ZIP Code)

ITEMS BELOW TO BE COMPLETED BY THE DEPARTMENT OF VETERANS AFFAIRS Use reverse for "Remarks"
21. PROOFS REQUESTED FROM CLAIMANT OR OTHER (Specify)

20. PROOFS RECEIVED
DEATH

AGE
OTHER (Specify)

MARRIAGE

DEATH

(NAME)
(NAME)

AGE
OTHER (Specify)

(NAME)
22. DATE

MARRIAGE

(NAME)
(NAME)
(NAME)

23. NAME AND ADDRESS OF TRANSMITTING VA OFFICE

Form SSA-24 (2-2002) Destroy All Prior Editions

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IMPORTANT: PLEASE READ THE FOLLOWING BEFORE YOU COMPLETE THE SSA-24.
INSTRUCTIONS FOR COMPLETING FORM SSA-24, APPLICATION FOR SURVIVORS BENEFITS
(Payable Under Title II of the Social Security Act)
This application form, SSA-24, is an Application for Survivors Benefits Payable under Title II of the Social
Security Act, as amended. Under authority of section 202(o) of the Social Security Act, the application requests
information in order to determine eligibility to social security benefits.
You do not have to complete this application; there are no penalties under the law if you do not complete part or
all of the SSA-24. However, it is usually to your advantage to provide the information because not providing it
could prevent an accurate and timely decision on your claim or could result in the loss of some benefits or
insurance coverage.
If you do wish to supply the information requested on the SSA-24, this information will be forwarded to the Social
Security Administration and used by them to determine whether social security benefits may be payable to
surviving dependent(s) of the veteran. Social Security will then contact you regarding any social security
benefits payable based on information given on this form.
Please understand that Social Security may, in certain instances, disclose the information on this form to another
Federal, State or local agency or individual without your written consent. This would be done in order to:
enable a third party or an agency to assist Social Security in establishing an individual's right to benefits or
coverage;
comply with Federal laws which require or authorize the release of information from social security records;
and
facilitate statistical research and audit activities necessary to assure the integrity and improvement of the
social security programs.
If you should have any question about entitlement to social security benefits or the information you have
provided on this form, please contact your local social security office.
Complete each item of the attached application, Form SSA-24, (except Items 20 through 23). When signed and
dated the form SHOULD BE LEFT ATTACHED to your completed
VA FORM 21-534, Application for Dependency and Indemnity Compensation, Death Pension and
Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable) or
VA FORM 21-535, Application for Dependency and Indemnity Compensation by Parent(s)
(Including Accrued Benefits and Death Compensation When Applicable).
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these
questions unless we display a valid Office of Management and Budget control number. We estimate that it will
take you about 15 minutes to read the instructions, gather the necessary facts, and answer the questions.

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File Type	application/pdf
File Modified	2011-01-28
File Created	2008-06-05