Form VA Form 21-0538 VA 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 change in the number of
dependents.
To show continued entitlement to this additional amount, you must complete and return the form on
page 2 of this letter. If the number of your dependents has not changed, we will continue your
benefits at their present rate. If the number of your dependents has changed due to either the loss or
addition of a dependent, we will adjust 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 dependents.
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 an
authorized veteran's service organization.
Veterans Service Center Manager
Enclosure

VA FORM
XXXX

21-0538

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OMB Approved No. 2900-0500
Respondent Burden: 10 Minutes
Expiration Date: XXXX

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 ore 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, Vocational Rehabilitation and Employment Records VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. You must give us your and your dependents SSN account information.
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). 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.reginfo.gov/public/do/PRAMain If desired, you may call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
IMPORTANT: If you are certifying that you are married for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse resided at
the time of marriage, or where you and/or your spouse resided when you filed your claim (or a later date when you became eligible for benefits.) (38 U.S.C. § 103(c)). Additional
guidance on when VA recognizes marriages is available at http://www.va.gov/opa/marriage/.
1. FIRST - MIDDLE - LAST NAME OF VETERAN

2. ARE YOU MARRIED?
YES

3A. DATE OF MARRIAGE (Month, day, year)

3B. PLACE OF MARRIAGE (City, State)

3D. SOCIAL SECURITY NUMBER OF SPOUSE

NO

(If "Yes," complete Items 3A-3E)

3C. TO WHOM WERE YOU MARRIED? (First name, Middle Initial, Last Name)

3E. DATE OF BIRTH OF SPOUSE (Month, 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 6, "Remarks," giving the information requested in Items 4A thru 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
(MONTH, DAY, YEAR)

4C. PLACE OF
BIRTH
(CITY, STATE)

4D. SOCIAL SECURITY
NUMBER

4E. NAME AND ADDRESS OF PERSION
HAVING CUSTODY OF THE CHILD
(If child is not in the custody of person claiming
dependency allowance)

NOTE: Furnish the following information for each terminated dependent.
5A. FULL NAME OF
EACH DEPENDENT

5B. PROVIDE REASON
FOR TERMINATION
(death, divorce, age)

5C. DATE OF TERMINATION

6. REMARKS

A. DAYTIME

7. TELEPHONE NUMBER(S) (Include Area Code)
B. EVENING

C. CELL PHONE

I HEREBY CERTIFY THAT the information I have given on this form is true and correct to the best of my knowledge and belief.
8A. SIGNATURE OF VETERAN OR GUARDIAN
8B. DATE SIGNED
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.
VA FORM 21-0538, XXXX

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