Form 21-4170 Statement of Marital Relationship

OMB Control No. 2900-0114
Respondent Burden: 25 Mins.

STATEMENT OF
MARITAL RELATIONSHIP

VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)

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 (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 SSN
account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). 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 eligibility for additional benefits as a spouse of a veteran or eligibility for pension or
dependency and indemnity compensation as the surviving spouse of a veteran (38 U.S.C. 101, 103, and 1102). We estimate that you will need an average of
25 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to
send comments or suggestions about this form.
INSTRUCTIONS: This form is to be completed by the veteran (if living) and the person who is claiming to be the spouse or surviving spouse. Note: For the
purposes of this form, the person who is claiming to be the spouse or surviving spouse is referred to as "spouse or surviving spouse." Print all answers clearly.
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
14, "Remarks, " or attach a separate sheet, indicating the item number to which the answers apply.
IMPORTANT INFORMATION: Submit any documents that show the veteran and the spouse or surviving spouse as husband and wife; for example, lease
agreements, joint bank statements, utility bills, tax returns, insurance forms, employment records, and any other documents showing marital status. Original
documents will be returned to you.
SECTION I - INFORMATION ABOUT THE VETERAN AND THE SPOUSE OR SURVIVING SPOUSE

1. NAME OF VETERAN (First, middle, last)
4. SOCIAL SECURITY NUMBER
OF SPOUSE OR SURVIVING
SPOUSE

3. NAME OF SPOUSE OR SURVIVING SPOUSE (First, middle, last)

2. VA FILE NUMBER

C/SS -

5. DATE OF BIRTH OF SPOUSE OR
SURVIVING SPOUSE (Month, day,

year)

6. COMPLETE ADDRESS OF VETERAN OR CLAIMANT (Number and street or rural route,

city or P. O., State and ZIP Code)

SECTION II - INFORMATION ABOUT THE CLAIMED MARITAL RELATIONSHIP
7B. PLACE YOU BEGAN LIVING AS HUSBAND AND WIFE (Include number and street or rural route, city or P. O.,
State and ZIP Code)

7A. DATE YOU BEGAN LIVING AS HUSBAND
AND WIFE (Month, day, year)

7C. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS HUSBAND AND WIFE (First, middle, last)

7D. TO BE COMPLETED BY THE SPOUSE OR SURVIVING SPOUSE:
AFTER YOU BEGAN LIVING WITH THE VETERAN, DID YOU USE HIS/HER LAST NAME?
ALWAYS

SOMETIMES

8. WHAT DID YOU AGREE YOUR RELATIONSHIP WOULD BE AT THE
TIME YOU BEGAN LIVING TOGETHER?

NEVER

9A. HAVE (HAD) YOU LIVED TOGETHER CONTINUOUSLY FROM THAT TIME UNTIL THIS DATE (OR THE VETERAN'S DEATH)?
YES

NO

(If "Yes," go to Item 10. If "No," complete Item 9B)
9B. LIST ALL PERIODS OF SEPARATION

BEGINNING DATE

ENDING DATE

(Month, day, year)

(Month, day, year)

BEGINNING DATE

ENDING DATE

REASON FOR SEPARATION

10. LIST ALL PERIODS OF TIME AND PLACES WHERE YOU LIVED AS HUSBAND AND WIFE

(Month, day, year)

VA FORM
JUL 2011

(Month, day, year)

21-4170

ADDRESS (Street address, city, and State)

EXISTING STOCKS OF VA FORM 21-4170, OCT 2004,
WILL BE USED.

SECTION III - INFORMATION ABOUT YOUR CHILDREN

IMPORTANT INFORMATION: Send a certified copy of the public record of birth for each child listed in Item 11B.

11A. HAVE YOU HAD CHILDREN TOGETHER?
NO

YES

(If "Yes," complete Item 11B. If "No," go to Item 12A.)
11B. FULL NAME OF CHILD (First, middle, last)

11C. PLACE OF BIRTH (City/State or Country)

SECTION IV - INFORMATION ABOUT YOUR MARITAL HISTORY

INSTRUCTIONS: Furnish complete information about all marriages of the veteran and spouse or surviving spouse. If you need additional space,
please attach a separate sheet of paper providing the requested information about the marriages.
IMPORTANT INFORMATION: Attach a copy of divorce decrees.

12A. HAS (HAD) THE VETERAN EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?
YES

NO

12B. DATE OF
MARRIAGE

(If "Yes," complete Items 12B through 12G. If "No," go to Item 13A.)
12D. TO WHOM MARRIED

12C. PLACE

(Month, day,
year)

(City/State or country)

(First name, middle initial, last
name)

12E. DATE
MARRIAGE
ENDED

(Month, day,
year)

12F. PLACE

(City/State or country)

12G. HOW
MARRIAGE
ENDED

(Death,
divorce, etc.)

13A. HAS THE SPOUSE OR SURVIVING SPOUSE EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?
YES

13B. DATE OF
MARRIAGE

(Month, day,
year)

NO

(If "Yes," complete Item 13B through 13G. If "No," go to Item 14.)
13C. PLACE

13D. TO WHOM MARRIED

(City/State or country)

(First name, middle initial, last
name)

13E. DATE
MARRIAGE
ENDED

(Month, day,
year)

13F. PLACE

(City/State or country)

13G. HOW
MARRIAGE
ENDED

(Death,
divorce, etc.)

14. REMARKS

SECTION V - CERTIFICATION, SIGNATURE(S), AND WITNESSES

I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge and belief.
15A. SIGNATURE OF VETERAN

15B. DATE SIGNED

16A. SIGNATURE OF CLAIMED SPOUSE OR SURVIVING SPOUSE

16B. DATE SIGNED

WITNESSES TO SIGNATURES IF MADE BY "X" MARK
NOTE: Signature by mark must be witnessed by two persons to whom the veteran or the claimed spouse or surviving spouse is personally known and the signatures and
addresses of the witnesses must be entered below.
17A. SIGNATURE OF WITNESS

17B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

18A. SIGNATURE OF WITNESS

18B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

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.
VA FORM 21-4170, JUL 2011