Form VA Form 21P-535 VA Form 21P-535 Application for Dependency and Indemnity Compensation by

General Instructions
For Application for Dependency and Indemnity Compensation by Parent(s) (Including Accrued Benefits and
Death Compensation when Applicable)
VA Form 21P-535
Note: Read very carefully, detach, and keep these instructions for your reference.
Benefit rates and income limits are frequently changed, so
A. How can I contact VA if I have questions?
it is not possible to keep this information current in these
If you have any questions about this form, how to fill it
instructions. You can find out what the current income
out, or about VA benefits, contact your nearest VA
limitations and rates of benefits are by contacting your
regional office. You can locate the address of the nearest
nearest VA regional office. You can locate your local VA
regional office in your telephone book blue pages under
regional at the following web site www.va.gov/directory.
"United States Government, Veterans" or call 1-800-827Note: Unless a claim for DIC is filed within one year from
1000 (Hearing Impaired TDD line 711). You may also
the date of the veteran's death, that benefit is not payable
contact VA by Internet at https://iris.va.gov.
from a date earlier than the date VA receives the claim.
B. What is the purpose of VA Form 21P-535?
E. How do I apply for the aid and attendance
allowance?
Use VA Form 21P-535 to apply for:
VA benefits you may be entitled to receive as the
surviving parent(s) of a deceased veteran
Any money VA owes the veteran but did not pay
prior to his/her death (accrued benefits).
If you apply for one of these benefits, the law requires that
we also consider your entitlement for the other.
C. What is the purpose of the attached SSA-24 form?
You can apply for Social Security benefits by using the
SSA-24 form attached to this VA form (see pages 7 and
8). 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 is dependency and indemnity compensation
(DIC), and how does VA decide what I will or will not
receive?
DIC may be payable to parent(s) when:
a veteran's death occurred in service, or
a veteran dies of a service-connected disability,
your income is limited.
VA pays Parents' DIC based on the amount of the
claimant's countable income and whether the claimant is
the sole surviving parent of the veteran or one of two
parents. This is based on law. If the claimant is married
and lives with his/her spouse, the claimant's and the
spouse's income are counted. VA must include as income
payments received from all sources that Federal law
specifies.

21P-535

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
44, "Remarks, " or attach a separate sheet, indicating the
item number to which the answers apply. Make sure you
sign and date this application (Items 40a through 41b).
Note: If the claim is being made on behalf of an
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
incompetent person.
G. What do I do when I have completed my
application?

AND

VA FORM
XXX 2014

VA may pay a higher rate of DIC to a surviving parent
who is blind, a patient in a nursing home, or otherwise
needs regular aid and attendance. If you wish to apply for
this benefit, check "yes" for Item 29.

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.

SUPERSEDES VA FORM 21-535, JUN 2014,
WHICH WILL NOT BE USED.

Page 1

H. How can I assign someone to act as my
representative?
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. If you appeal the
decision, agents and attorneys can charge you for services
that you receive from them only after the Board of
Veterans' Appeals (BVA) gives you its 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.
If you want to use a representative to help you with your
application, contact the nearest VA regional office.
Depending on the type of representative you want to
designate, we will send you one of the following forms:
VA Form 21-22, Appointment of Veterans Service
Organization as Claimant's Representative,

or VA Form 21-22a, Appointment of Individual as
Claimant's Representative.
You may also download these forms at
www.va.gov/vaforms/. If you have already designated a
representative, no further action is required on your part.
I. What if I believe that VA has made an error in
processing or deciding my benefits?
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
regional office and tell them that you want a personal
hearing on your case. Someone in the local VA regional
office will arrange a time and a place for your hearing. At
this hearing, you may 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.

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/.
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, 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. 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. 1121,
1310, 1315, and 5121. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 1
hour and 12 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.

VA FORM 21P-535, XXX 2014

Page 2

OMB Control No. 2900-0005
Respondent Burden: 1 hour and 12 minutes
Expiration Date: XXXXXXXX
DO NOT WRITE IN THIS SPACE
(VA DATE STAMP)

Application for Dependency and Indemnity Compensation by Parent(s)
(Including Accrued Benefits and Death Compensation when Applicable)

IMPORTANT: Please read the attached "General Instructions" before you fill out this form.
SECTION I: VETERAN'S IDENTIFICATION

1. DID THE VETERAN EVER FILE A CLAIM WITH VA?

Yes

No

2. WHAT IS THE VETERAN'S VA FILE NUMBER?

(If "Yes," answer Item 2)

3. HAVE YOU EVER FILED A CLAIM WITH VA?

Yes

No

4. WHAT IS YOUR VA FILE NUMBER?

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

5. NAME OF PERSON ON WHOSE SERVICE THE CLAIM WAS FILED? (First, Middle, Last)

6. WHAT IS YOUR RELATIONSHIP TO THAT PERSON?

7. VETERAN'S NAME? (First, Middle, Last)

8. VETERAN'S SOCIAL SECURITY NUMBER (SSN)?

9A. DID THE VETERAN SERVE UNDER ANOTHER NAME?

9B. LIST THE OTHER NAME(S) THE VETERAN SERVED UNDER:

Yes

No

(If "Yes," answer Item 9B)
11. VETERAN'S DATE OF DEATH? (Month, Day, Year)

10. VETERAN'S DATE OF BIRTH? (Month, Day, Year)

NOTE: Attach a copy of the death certificate unless the veteran died while serving in the Army, Navy, Air Force, Marine Corps, or Coast Guard, or as a
commissioned officer in the National Oceanic and Atmospheric Administration, Coast and Geodetic Survey, Environmental Science Services
Administration, or Public Health Service, or in a hospital or institution under the control of the U.S. government.
SECTION II: VETERAN'S ACTIVE DUTY SERVICE
NOTE: SKIP TO SECTION III IF THE VETERAN WAS RECEIVING VA COMPENSATION OR PENSION AT THE TIME OF HIS/HER
DEATH. 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.
If more space is needed use Item 33, "Remarks,".
12A. VETERAN ENTERED ACTIVE SERVICE (Month, Day, Year)

12B. PLACE ENTERED ACTIVE SERVICE

12C. SERVICE NUMBER

12D. VETERAN LEFT ACTIVE SERVICE (Month, Day, Year)

12E. PLACE LEFT ACTIVE SERVICE

12F. BRANCH OF SERVICE

12G. GRADE, RANK
OR RATING

SECTION III: VETERAN'S PARENT(S) INFORMATION

NOTE: Parent means a biological or adoptive parent, or a foster parent. A foster parent is a person who stood in the relationship of a
parent to a veteran for at least one year before the veteran's last entry into active service. The foster relationship must have begun prior
to the veteran's 21st birthday. If you are claiming benefits as the foster parent of the veteran, you will also need to complete VA Form
21P-524, Statement Of Person Claiming To Have Stood In Relation of Parent. If you need a copy of this form, you may download the
form at www.va.gov/vaforms. Note: Only one parent can be recognized for benefit payment purposes.
• The age of majority is determined by State law and is age 18 in most States. Contact your State government for more information.
• Parental control is considered to have been given up if the parent has ceased to provide for the child and the normal parent/child
relationship has been broken.
• Provide a copy of the veteran's public record of birth or a copy of the court record of adoption if the veteran was adopted.
13A. PARENT'S NAME? (First, Middle, Last)

13B. PARENT'S ADDRESS (Street address, rural route, or P.O. box, Apt. No.,
City, State, ZIP Code and Country)

13D. PARENT'S DATE OF DEATH (MM,DD,YYYY)

13C. PARENT'S DATE OF BIRTH (MM,DD,YYYY)

13E. PARENT'S SOCIAL SECURITY NUMBER

(If deceased, complete Item 13D)
13F. PARENT'S TELEPHONE NUMBER(S) (Include Area Code)

13G. PARENT'S E-MAIL ADDRESS (If applicable)

Daytime:________________________
Evening:_________________________
VA FORM
XXX 2014

21P-535

SUPERSEDES VA FORM 21-535, JUN 2014,
WHICH WILL NOT BE USED.

Page 3

SECTION III: VETERAN'S PARENT(S) INFORMATION (Continued)
14B. PARENT'S ADDRESS (Street address, rural route, or P.O. box, Apt. No.,
City, State, ZIP Code and Country)

14A. PARENT'S NAME? (First, Middle, Last)

14C. PARENT'S DATE OF BIRTH (MM,DD,YYYY)

14D. PARENT'S DATE OF DEATH (MM,DD,YYYY)

14E. PARENT'S SOCIAL SECURITY NUMBER

(If deceased, complete Item 16B)
14G. PARENT'S E-MAIL ADDRESS (If applicable)

14F. PARENT'S TELEPHONE NUMBER(S) (Include Area Code)

Daytime:________________________
Evening:_________________________
15A. WAS THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL CONTROL 15B. DATE(S) OF PARENTAL CONTROL (MM,DD,YYYY)
AT ALL TIMES BEFORE HE/SHE REACHED THE AGE OF MAJORITY?
From:
To:
YES

NO

(If "NO," answer Items 18b through 18d)

From:

To:

15C. WHY WASN'T THE VETERAN A MEMBER OF YOUR HOUSEHOLD OR UNDER YOUR PARENTAL CONTROL AT ALL TIMES BEFORE HE/SHE REACHED THE
THE AGE OF MAJORITY? (Explain fully)

15D. NAME AND ADDRESS OF EACH PERSON WHO ASSUMED PARENTAL CONTROL OVER THE VETERAN OUTSIDE THE DATE(S) SHOWN IN ITEM 18B.

SECTION IV: VETERAN'S PARENT(S) MARITAL HISTORY
16. WHAT IS YOUR MARITAL STATUS? (Check one)
MARRIED AND LIVE WITH OTHER PARENT OF VETERAN
MARRIED AND LIVE WITH SPOUSE WHO IS NOT THE OTHER PARENT OF VETERAN
SEPARATED, MARRIED BUT NOT LIVING WITH SPOUSE, IF CHECKED PROVIDE DATE OF SEPARATION:________________________________
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.

DIVORCED, IF CHECKED PROVIDE DATE OF DIVORCE:______________________________
WIDOWED, IF CHECKED PROVIDE DATE OF DEATH OF YOUR SPOUSE:______________________________
NEVER MARRIED, IF CHECKED SKIP TO SECTION IV
17A. WHAT IS YOUR SPOUSE'S NAME (First, Middle, Last)

17D. IS YOUR SPOUSE ALSO A VETERAN?
NO
(If "Yes," answer Item 17E)
YES

VA FORM 21P-535, XXX 2014

17B. SPOUSE'S DATE OF BIRTH (MM,DD,YYYY)

17C. SPOUSE'S SOCIAL SECURITY NUMBER

17E. WHAT IS YOUR SPOUSE'S VA FILE NUMBER (If any)

Page 4

SECTION V: INFORMATION REGARDING PARENT'S NEED FOR NURSING HOME CARE OR AID AND ATTENDANCE
18. ARE YOU CLAIMING THE AID AND ATTENDANCE ALLOWANCE BECAUSE YOU NEED THE REGULAR ASSISTANCE OF ANOTHER PERSON OR HAVE SEVERE
VISUAL PROBLEMS?
YES

(If "No," skip to Section V)

NO

NOTE: If you answered "Yes," to Item 18 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, and the amount you pay-out-of-pocket for your care.
19B. PROVIDE THE NAME AND COMPLETE MAILING ADDRESS OF THE NURSING HOME

19A. ARE YOU NOW IN A NURSING HOME?
YES

(If "Yes," answer Item 19B also)

NO

SECTION VI: INFORMATION REGARDING PARENT'S INCOME
IMPORTANT - Payments from any source will be counted, unless the law indicates that they don't need to be counted. Report all income in the boxes
below, and VA will determine any amount that does not count.
20. HAVE YOU CLAIMED OR ARE YOU RECEIVING
BENEFITS FROM THE SOCIAL SECURITY
ADMINISTRATION?
YES

NO

21. HAVE YOU FILED A CLAIM FOR COMPENSATION FROM
THE OFFICE OF WORKER'S COMPENSATION PROGRAMS
BASED ON THE DEATH OF THE VETERAN?
YES

NO

22. HAS A COURT AWARDED DAMAGES
BASED ON THE DEATH OF THE VETERAN OR
IS A CLAIM O LEGAL ACTION FOR DAMAGES
PENDING?
YES

NO

Report the total amounts before you take out deductions for taxes, insurance, etc.
Do not report the same income 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.
VA will interpret a blank space to mean "0" or "None".
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.
Monthly Income - Report The Income You And Your Spouse Receive Monthly
Note: If you are filing this application as the guardian or custodian of the veteran's parent, do not report your own income.

23a. Social Security

Spouse

Parent

Sources of recurring monthly income

$

(If living together)
$

23b. U.S. Civil Service
23c. U.S. Railroad Retirement
23d. Military Retirement
23e. Black Lung Benefits
23f. Other income received monthly (Please write source below)

23g. Other income received monthly (Please write source below)

Annual Income By Calendar Year- Tell Us About Annual Income For You And Your Spouse
NOTE: Report income received from January 1 to the date of the veteran's death. If the claim is filed more than one year after the veteran died, report
the income you received from January 1 to the date you sign this application.

Sources of recurring monthly income
24a. Gross wages and salary

Spouse

Parent
$

(If living together)
$

24b. Total dividends and interest
24c. Life insurance
24d. Other income expected (Please write source below)

VA FORM 21P-535, XXX 2014

Page 5

SECTION VII: INFORMATION REGARDING MEDICAL, LAST ILLNESS AND BURIAL OR OTHER REIMBURSED EXPENSES
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 fees you pay. Also, show
unreimbursed last illness and burial expenses you paid. Last illness and burial expenses are unreimbursed amounts paid by you for
the last illness and burial of the veteran or your spouse at any time prior to the end of the year following the year of death. Show
medical, legal or other expenses you paid because of a claim for compensation for injury or death for which civilian disability or death
benefits have been awarded. When determining your countable income, we may be able to deduct these expenses from the disability
benefits for the year in which the expenses are paid. 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,use
Remarks, Item 33, or attach a separate sheet.

25a. Amount paid by
you

25b. Date Paid
(MM,DD,YYYY)

25c. Purpose
(Medicare deduction,
doctor's fees, burial
expenses, etc.)

25d. Paid To
(Name of Doctor,
hospital, pharmacy, etc.)

25e. Relationship of person
for whom expenses were paid

SECTION VIII: DIRECT DEPOSIT INFORMATION
The Department of Treasury requires all Federal payments 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 26, 27, and 28 to enroll in Direct Deposit. If you do not
have a bank account, you must receive your payment through Direct Express Debit MasterCard. To request a Direct Express Debit MasterCard you
must apply at www.usdirectexpress.com or by telephone at 1-800-333-1795. If you elect not to enroll, you must contact representatives handling
waiver requests for the Department of Treasury at 1-888-224-2950. They will encourage your participation in EFT and address any questions or
concerns you may have.
NOTE: You can either attach a voided check, or answer Items 26, 27 and 28.
26. ACCOUNT NUMBER (Please check the appropriate box and provide that account number, if applicable)

Checking
Savings

I certify that I do not have an account with a financial institution
or certified payment agent

Account number
27. NAME OF FINANCIAL INSTITUTION

28. ROUTING OR TRANSIT NUMBER

VA FORM 21P-535, XXX 2014

Page 6

SECTION IX: CERTIFICATION AND SIGNATURE

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.
29a. SIGNATURE OF PARENT, FOSTER PARENT, GUARDIAN OR CUSTODIAN

29b. DATE SIGNED

30a. SIGNATURE OF PARENT, FOSTER PARENT, GUARDIAN OR CUSTODIAN

30b. DATE SIGNED

NOTE: If you sign with an "X,"then you must have two people you know witness you as you sign. They must then sign the form and
print their names and addresses also.

31a. SIGNATURE OF WITNESS (If claimant signed above using an "X")

31b. PRINTED NAME AND ADDRESS OF WITNESS

32a. SIGNATURE OF WITNESS (If claimant signed above using an "X")

32b. PRINTED NAME AND ADDRESS OF WITNESS

SECTION X: REMARKS
33. 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 Section and Item number)

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

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.
VA FORM 21P-535, XXX 2014

Page 6

Form Approved
OMB Control 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
1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN (Type or print)

VA DATE STAMP

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 PARENT

5. PLACE OF BIRTH
8. DID THE VETERAN WORK IN THE RAILROAD
INDUSTRY AT ANY TIME AFTER 1936?

7. MAIDEN NAME OF PARENT

YES

NO

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.
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)
14. DATE (Month, day, year)

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

PAGE 7

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 21P-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 21P-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.

PAGE 8