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,
58VA21/22,28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment 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.reginfo.gov/public/do/PRAMain. 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 apply.
3. FIRST NAME - MIDDLE NAME - LAST NAME OF
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN 2. FILE NUMBER
CLAIMANT (SPOUSE OR SURVIVING SPOUSE)

C/CSS-

4B. 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.
6A. HOW LONG HAD/HAVE 6B. HOW LONG HAD / HAVE
5A. WHAT WAS/IS YOUR RELATIONSHIP 5B. WHAT WAS / IS YOUR
YOU KNOWN THE
YOU KNOWN THE
RELATIONSHIP TO THE
TO THE VETERAN? (Parent, child,
CLAIMANT? (Parent, child,
VETERAN? (Months,
CLAIMANT? (Months, years)
brother, sister, etc. If not related, state

years)

brother, sister, etc. If not related,
state"None")

"None")

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

NO

YES

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 "REMARKS" (If

necessary use section on reverse and key answers to item number)

(If "Yes," complete Item 10B)
11. NAME(S) BY WHICH CLAIMANT WAS/IS KNOWN
LAST NAME

FIRST 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?
NO (If "Yes," complete Item 13B)
YES
13B. PERIODS OF TIME AND PLACES WHERE THE VETERAN AND THE CLAIMANT HAD/HAVE LIVED TOGETHER
BEGINNING DATE

VA FORM
JUN 2011

21-4171

ENDING DATE

CITY OR TOWN

EXISTING STOCKS OF VA FORM 21-4171, NOV 2004,
WILL BE USED.

STATE

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

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

NO

(If "Yes," complete Item 15B)

TO WHOM MARRIED

15B. OTHER MARRIAGES OF VETERAN
HOW MARRIAGE
DATE AND PLACE
TYPE OF MARRIAGE
ENDED
OF MARRIAGE
(Ceremonial, etc.)

(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

18C. DAYTIME TELEPHONE NUMBER (Including Area Code)

18B. DATE SIGNED

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.
VA FORM 21-4171, JUN 2011