Form VA Form 21P-534 VA Form 21P-534 Application for Dependency and Indemnity Compensation, D

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 21P-534

Note: Read very carefully, detach, and keep these instructions for your reference.
A. How can I contact VA if I have questions?
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 at www.
va.gov/directory or you may call 1-800-827-1000 (Hearing Impaired TDD line is 711). You may also contact VA by Internet at https://iris.va.gov .

B. What is the purpose of VA Form 21P-534?
Use VA Form 21P-534 to apply for:
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 or her death (accrued benefits).
NOTE: 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 11 and 12). 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.
2. Death pension may be payable when:
the death of a veteran with wartime service is not due to service, and
income is within applicable limits.
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 dependency and indemnity compensation or death pension is filed within 1 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.
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 51, "Remarks, " or attach a separate sheet, indicating the item number to
which the answers apply. Make sure you sign and date this application (Items 48A and 48B).

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.
VA FORM
XXX 2014

21P-534

SUPERSEDES VA FORM 21-534, JUN 2014,
WHICH WILL NOT 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. You can find the mailing address of
your local VA regional office at www.va.gov/directory.

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. Agents and attorneys can charge you for services that you get from them only after the
Board of Veteran's 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.
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:
• VA Form 21-22, Appointment of a 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 office and tell them that you want a personal hearing on your case.
Someone in the local VA office will arrange a time and 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.

PRIVACY ACT INFORMATION: 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, 58VA21/22/28 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. 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 1
hour and 15 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-534, XXX 2014

General Instructions

PAGE 2

OMB Approved No. 2900-0004
Respondent Burden: 1 hour 15 minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR DEPENDENCY AND INDEMNITY COMPENSATION,
DEATH PENSION AND ACCRUED BENEFITS BY A SURVIVING SPOUSE OR CHILD
(Including Death Compensation if Applicable)

IMPORTANT - Read the attached "General Instructions" before you fill out this form.

PART I - CLAIM INFORMATION (Tell us what you are applying for and what you and the deceased veteran have applied for)
1. DID THE VETERAN EVER FILE A CLAIM WITH VA ?
NO (If "Yes," answer Item 2)
YES

2. WHAT IS THE VA FILE NUMBER? (If known)

3. HAS THE SURVIVING SPOUSE OR CHILD EVER FILED A CLAIM WITH VA?
YES
NO (If "Yes," answer Items 4 through 6)

(DO NOT WRITE IN THIS
SPACE)
(VA DATE STAMP)

4. WHAT IS THE VA FILE NUMBER? (If known)

5. WHAT IS THE NAME OF THE PERSON ON WHOSE SERVICE THE CLAIM WAS FILED? (First, Middle, Last Name of Veteran)
7. ARE YOU CLAIMING SERVICE CONNECTION FOR CAUSE OF DEATH?

6. WHAT IS YOUR RELATIONSHIP TO THAT PERSON?

YES

NO

PART II - IDENTIFYING INFORMATION (Provide information about you and the deceased veteran)
8. WHAT IS THE VETERAN'S NAME? (First, Middle, Last Name of Veteran) (Suffix - if applicable)

10A. DID THE VETERAN SERVE UNDER ANOTHER NAME?

9. VETERAN'S SOCIAL SECURITY NO.

10B. LIST THE OTHER NAME(S) THE VETERAN SERVED UNDER

NO (If "Yes," answer Item 10B)

YES

11. WHAT IS THE VETERAN'S DATE OF BIRTH (Month, Day, Year)

12. WHAT IS THE VETERAN'S DATE OF DEATH (Month, Day, Year)
(NOTE: 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?

14. WHAT IS YOUR NAME? (First, Middle, Last Name of Veteran's Spouse or Child)

YES

NO

15. WHAT IS YOUR RELATIONSHIP TO THE VETERAN? (Check one)
SURVIVING SPOUSE

16. WHAT IS YOUR ADDRESS (Number and street or rural route, city or P.O., State,

ZIP Code and Country)

CHILD
17. WHAT ARE YOUR TELEPHONE NUMBERS? (Include Area Code)
DAYTIME

18. WHAT IS YOUR E-MAIL ADDRESS?

CELL PHONE

EVENING

20. WHAT IS THE YOUR DATE OF BIRTH (Month, Day, Year)

19. WHAT IS YOUR SOCIAL SECURITY NUMBER?

PART III - VETERAN'S ACTIVE DUTY SERVICE
NOTE: Skip to Part IV if the veteran was receiving VA Compensation or Pension at the time of his or her death.
IMPORTANT: Enter complete information for all periods of service. If more space is needed use Item 51 "Remarks". 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.
21A. ENTERED ACTIVE
SERVICE - First Period

(Month, Day, Year)

21B. PLACE ENTERED ACTIVE
SERVICE - First Period

(Month, Day, Year)

21I. PLACE ENTERED ACTIVE
SERVICE - First Period

21L. PLACE LEFT ACTIVE
SERVICE - Second Period

VA FORM
XXX 2014

21P-534

21D. DATE LEFT ACTIVE
SERVICE - First Period

(Month, Day, Year)

21F. BRANCH OF SERVICE

21E. PLACE LEFT ACTIVE
SERVICE - First Period

21H. ENTERED ACTIVE
SERVICE - Second Period

21C. SERVICE NUMBER

21J. SERVICE NUMBER

21G. GRADE, RANK,
OR RATING

21K. DATE LEFT ACTIVE
SERVICE - Second Period

(Month, Day, Year)

21M. BRANCH OF SERVICE

SUPERSEDES VA FORM 21-534, JUN 2014,
WHICH WILL NOT BE USED.

21N. GRADE, RANK,
OR RATING

PAGE 3

PART IV- MARITAL INFORMATION
(Attach a copy of your marriage certificate showing your marriage to the veteran)
NOTE: You must furnish complete information about all marriages of the surviving spouse and the veteran. If you are claiming benefits as the surviving
spouse of the veteran you should complete Items 22A through 28. If you are not the surviving spouse skip Items 23A through 28.
TELL US ABOUT THE VETERAN'S MARRIAGES
22A. HOW MANY TIMES WAS THE VETERAN MARRIED? (Include marriage to you)

22B. DATE (month, day, year) and PLACE
OF MARRIAGE (city, state or country)

22C. TO WHOM MARRIED
(first, middle, last name)

22D. TYPE OF MARRIAGE 22E. HOW MARRIAGE
(ceremonial, common-law,
TERMINATED
proxy, tribal, or other)
(death, divorce)

22F. DATE (month, day, year) and
PLACE MARRIAGE TERMINATED
(city/state or country)

22G. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 22D, PLEASE EXPLAIN:

TELL US ABOUT YOUR MARRIAGES

23A. HOW MANY TIMES HAVE YOU BEEN MARRIED? (Include your marriage to the
veteran)

23B. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?

Provide information in Items 23c through 23G for all of your marriages)
23C. DATE (month, day, year) and PLACE
OF MARRIAGE (city/state or country)

23D. TO WHOM MARRIED
(first, middle, last name)

NO

YES

23F. HOW MARRIAGE
23G. DATE (month, day, year)
TERMINATED
and PLACE MARRIAGE
(death, divorce, marriage has not
TERMINATED
been terminated)
(city/state or country)

23E. TYPE OF MARRIAGE
(ceremonial, common-law,
proxy, tribal, or other)

23H. IF YOU INDICATED "OTHER" AS TYPE OF MARRIAGE IN ITEM 23E, PLEASE EXPLAIN:
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
YES
NO
less than one year)
26. DID YOU LIVE CONTINUOUSLY WITH THE VETERAN FROM THE DATE
OF MARRIAGE TO THE DATE OF HIS/HER DEATH?
YES

NO

25. ARE YOU EXPECTING THE BIRTH OF THE VETERAN'S CHILD?
YES

NO

27. WHAT WAS THE CAUSE OF 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," complete Item 27)

28. AT THE TIME OF YOUR MARRIAGE TO THE VETERAN, WERE YOU AWARE OF ANY REASON THE MARRIAGE MIGHT NOT BE LEGALLY VALID?
YES

NO

(If "Yes," provide explanation):___________________________________________________________________________________________

PART V: DEPENDENT CHILDREN (Complete ONLY if claiming benefits for a child(ren) of the veteran)
(Skip to Section VI if you are NOT claiming benefits for a child(ren) of the veteran)
29A. NAME OF CHILD
(First, middle initial, last name)

29B. DATE (month, day,
year) and PLACE OF
BIRTH
(city/state or country)

29C. SOCIAL
SECURITY
NUMBER

(Check all that apply)
29E.
29D.
29F.
BIOLOGICAL ADOPTED STEPCHILD

29G.
18-23 YEARS
OLD (in school)

29I.
29H.
29J. CHILD
CHILD PREVIOUSLY
SERIOUSLY
MARRIED
DISABLED
MARRIED

Tell us about the child(ren) listed in Item 29A that do not live with you in Items 30A through 30D.
30A. NAME OF CHILD
(First, middle initial, last name)

30B. CHILD'S COMPLETE ADDRESS
30D. MONTHLY AMOUNT YOU
30C. NAME OF PERSON THE CHILD
(Number and street or rural route, city or P.O., city,
CONTRIBUTE TO THE CHILD'S
LIVES WITH (If applicable)
State, ZIP Code and country)
SUPPORT

$
$
$
VA FORM 21P-534, XXX 2014

Page 4

PART VI: HOUSEBOUND, IN A NURSING HOME OR REQUIRE AID AND ATTENDANCE
NOTE: If you are 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 and 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, 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

NO
32B. PROVIDE THE NAME AND COMPLETE MAILING ADDRESS OF THE FACILITY

32A. ARE YOU NOW IN A NURSING HOME?
YES

NO

(If "Yes," answer Items 32B and 32C)

32C. DOES MEDICAID COVER ALL OR PART OF YOUR NURSING HOME COSTS?
YES

(If "No," answer Item 32D)

NO

32D. HAVE YOU APPLIED FOR MEDICAID?
YES

NO

PART VII: TRANSFER OF ASSETS AND/OR PROPERTY
IMPORTANT: If the transfer involved a trust, annuity, or other similar arrangement please provide a copy of the trust or transfer documents.
33. HAVE YOU OR THE VETERAN'S DEPENDENT CHILD TRANSFERRED, GIVEN AWAY, OR SOLD ANY PROPERTY IN THE LAST 36 MONTHS (3 years), INCLUDING
THE PURCHASE OF AN ANNUITY, TRUST, OR OTHER FINANCIAL PRODUCTS THAT WILL PROVIDE FUTURE INCOME, OR PROPERTY PLACED IN A TRUST, IN
THE LAST 3 YEARS? (Report only those transfers over $1,500, including multiple/separate transfers to an individual or company so that the total equals $1,500 or more)

EXAMPLES OF TRANSFER ITEMS: Cash, house, mobile home, car tractor, livestock, motorized vehicles, land, time-shares, real property, gifts, etc.
YES

NO

(If "Yes," complete Items 34A through 34G)

34A. ITEM THAT
YOU OR YOUR
SPOUSE
TRANSFERRED, SOLD
OR GAVE AWAY

34B. DID THIS TRANSFER 34C. WHAT WAS 34D. TRANSFERRED TO
INVOLVE THE
THE MARKET
WHOM?
CREATION OF A TRUST
VALUE AT THE (If the transfer involved a
OR PURCHASE
TIME OF
trust, include tax id number
OF AN ANNUITY?
TRANSFER?
for the trust)

34G. AMOUNT YOU

34E. THEIR
RECEIVED IN EXCHANGE
RELATIONSHIP
FOR THIS TRANSFER
34F. DATE OF
TO YOU
(If you will receive recurring
TRANSFER
(If the transfer involved an
(mm/dd/yyyy) payments as a result of transfer,
annuity, include the type of
include that information in
annuity purchased)
Part IX)

$

Yes

No

$

Yes

No

$

Yes

No

$

$

Yes

No

$

$

Yes

No

$

$

Yes

No

$

$

Yes

No

$

Yes

No

$

Yes

No

$

$

Yes

No

$

$

$

$
$

35A. HAVE YOU OR THE VETERAN'S DEPENDENT CHILD IN THE PAST 3 YEARS OWNED OR HAD ANY INTEREST (including life estate, joint ownership, etc.)
IN ANY REAL PROPERTY OTHER THAN YOUR PRIMARY RESIDENCE?
YES

NO

(If "Yes," complete Item 35B and 35C) (NOTE: If you answered "Yes," to owning property other than your home, now or in the past 3 years, please
provide VA with a copy of the deed for that property)

35B. ADDRESS OF PROPERTY (Include County and State)

VA FORM 21P-534, XXX 2014

35C. DATE YOU SIGNED DEED TRANSFERRING
THIS PROPERTY (mm,dd,yyyy)

Page 5

PART VIII: NET WORTH (COMPLETE ONLY IF CLAIMING DEATH PENSION OR PARENTS DIC)
(Skip to PART IX if you are NOT claiming death pension benefits or parents DIC)

VA cannot pay you pension if your net worth is excessive. "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 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.
36A. NET WORTH - Provide amounts (DO NOT LEAVE ANY ITEMS BLANK. If your household has no net worth in a particular source, write "0" or "NONE".
If you leave a space blank, it will delay your claim.)
OWNER OF PROPERTY
SOURCE OF
NET WORTH

CASH

SURVIVING SPOUSE
OR CUSTODIAN
OF CHILD(REN)

$

CHILD
NAME:

$

BANK OR PAYOR
CHILD

CHILD
NAME:

$

NAME:

(Provide the name of
the financial institution
or business)

$

NON-INTEREST
BEARING CHECKING
ACCOUNTS
INTEREST-BEARING BANK
ACCOUNTS,
(Including savings, money
market accounts, certificates
of deposit (CDs) or any
accounts that
generate income reported on
a 1099-INT form that you
submit to the IRS)
RETIREMENT ACCOUNTS
(Including IRAs, SEP,
Qualified Plans,
Pensions, Annuities, etc.,
or any accounts that generate
income reported on a 1099-R
form that you submit to
the IRS)
INVESTMENTS IN
STOCKS, BONDS, OR
MUTUAL FUNDS THAT
GENERATE INCOME
REPORTED ON A
1000-DIV FORM THAT
YOU SUBMIT TO THE IRS
VALUE OF BUSINESS
ASSETS THAT YOU MAY
HAVE REPORTED ON A
SCHEDULE K-1 OF FORM
1120S, A SCHEDULE
K-1 OF FORM 1065, OR
SCHEDULE C THAT
YOU SUBMIT TO
THE IRS

VALUE OF REAL
PROPERTY AT THE
TIME THAT YOU SUBMIT
THIS FORM TO THE VA
(Not your home)
ANY OTHER
NON-PERSONAL
PROPERTY THAT IS
VALUED AT $1,500
OR MORE
ANY OTHER
FINANCIAL ACCOUNTS
THAT GENERATE
INCOME REPORTED
ON A 1099 FORM THAT
YOU SUBMIT TO
THE IRS (If you have
other financial accounts,
provide the
name/description of
this Source of Net Worth in
Item 36B)

36B. NAME/DESCRIPTION OF OTHER FINANCIAL ACCOUNT:

VA FORM 21P-534, XXX 2014

Page 6

PART IX: TOTAL GROSS INCOME
NOTE: Report the total gross income before deductions for taxes, insurance, etc. If you do not receive any payments from one of the sources listed,
write "0" or "NONE" in the space. If you leave a space blank, it will delay your claim. For all sources of income, you MUST submit the corresponding
IRS form, such as a W-2, or a 1099 form.
If you are receiving monthly VA benefits, you MUST submit a copy of your most recent award letter. This will help us determine the amount of benefits
you should be paid. VA counts all income, unless the law states that a particular source of income does not need to be counted.
37. MONTHLY INCOME - Provide amounts (DO NOT LEAVE ANY ITEMS BLANK. If no income was received from a particular source, write "0" or "NONE")
RECIPIENT
SOURCES OF
RECURRING MONTHLY SURVIVING SPOUSE
NAME:
OR CUSTODIAN
INCOME
OF CHILD(REN)

$

SOCIAL SECURITY

$

CHILD

PAYOR

CHILD

CHILD
NAME:

$

NAME:

HOW MANY
TIMES
LIST EACH PAYOR IN A YEAR DO
FROM WHICH
YOU RECEIVE
YOU RECEIVE
THIS
INCOME
PAYMENT?

DATE
OF PAYMENT
(Month/Year)

$

U.S. CIVIL SERVICE
U.S. RAILROAD
RETIREMENT
BLACK LUNG
BENEFITS
GROSS WAGES OR
SALARY
INCOME FROM
RETIREMENT
ACCOUNTS (IRAs, SEP,
Qualified Plans, Pensions,
Annuities, etc., or any
accounts for which you
receive a 1009-R form)
INCOME FROM TRUSTS
OR ESTATES FOR
WHICH YOU RECEIVED
A SCHEDULE K-1 OF
FORM 1040
INCOME FROM
BUSINESS ASSETS
THAT YOU MAY HAVE
REPORTED ON A
SCHEDULE K-1 OF
FORM 1120S, A
SCHEDULE K-1 OF
FORM 1065, OR
SCHEDULE C
INCOME FROM INTEREST
OR DIVIDENDS FOR
WHICH YOU RECEIVED
1099-INT OR 1099-DIV
FORM

WORKERS
COMPENSATION OR
UNEMPLOYMENT
COMPENSATION
OTHER SOURCE OF
INCOME FOR
WHICH YOU MAY
RECEIVE A 1099 FORM
OTHER SOURCE OF
INCOME FOR
WHICH YOU MAY
RECEIVE A 1099 FORM
38. WILL YOU RECEIVE ANY INCOME FROM RENTAL PROPERTY OR FROM THE OPERATION OF A BUSINESS WITHIN 12 MONTHS OF THE DAY YOU SIGN
THIS FORM?

(If "Yes," please complete and submit along with your completed application VA Form 21P-4185, Report of Income

YES

NO from Property or Business. This form is available at www.va.gov/vaforms)

39. WILL YOU RECEIVE ANY INCOME FROM THE OPERATION OF A FARM WITHIN 12 MONTHS OF THE DAY YOU SIGN THIS FORM?
YES

NO

(If "Yes," please complete and submit along with your completed application VA Form 21P-4165, Pension Claim
Questionnaire for Farm Income. This form is available at www.va.gov/vaforms)

VA Form 21P-534, XXX 2014

Page 7

PART IX: TOTAL GROSS INCOME (Continued)
40A. HAVE YOU CLAIMED OR ARE YOU RECEIVING BENEFITS FROM THE SOCIAL SECURITY ADMINISTRATION ON YOUR OWN BEHALF OR ON BEHALF OF
A CHILD OR CHILDREN IN YOUR CUSTODY?
YES

NO (If "Yes," answer Item 40B)

40B. IS SOCIAL SECURITY BASED ON YOUR OWN EMPLOYMENT?
YES

NO

41. 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

NO

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

NO

43. 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

PART X: MEDICAL, LAST ILLNESS, BURIAL OR OTHER UNREIMBURSED EXPENSES
44. 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 you need more space use Item 51, Remarks.
AMOUNT PAID BY YOU

DATE PAID
(mm/dd/yyyy)

PURPOSE
(Medicare deduction, nursing home costs,
burial expenses, etc.)

PAID TO (Name of nursing home,
hospital, funeral home, etc.)

RELATIONSHIP OF PERSON
FOR WHOM EXPENSES PAID
(Spouse, child, etc.)

$
$
$
$
$
$
$
$
$
$

PART XI : DIRECT DEPOSIT INFORMATION
The Department of Treasury requires all Federal benefit 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 45, 46, and 47 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.
45. ACCOUNT NUMBER (Check the appropriate box and provide the account number, or simply write "Established" if you have a direct deposit with VA.)
I CERTIFY THAT I DO NOT HAVE AN ACCOUNT WITH A FINANCIAL
CHECKING
SAVINGS
INSTITUTION OR CERTIFIED PAYMENT AGENT

Account No.:__________________

Account No.:__________________

46. NAME OF FINANCIAL INSTITUTION (Please provide the name of the bank
where you want your direct deposit)

VA FORM 21P-534, XXX 2014

47. ROUTING OR TRANSIT NUMBER (The first nine numbers located
at the bottom left of your check)

Page 8

PART XII - 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, and I waive any privilege which makes the information confidential.
48A. SIGNATURE (Provide your signature in the box, DO NOT PRINT) (If you sign with an "X," then you must have 2 people you
know witness as you sign. They must then sign the form and print their names and addresses)

49A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

49B. PRINTED NAME AND ADDRESS OF WITNESS

50A. SIGNATURE OF WITNESS (If claimant signed above using an "X")

50B. PRINTED NAME AND ADDRESS OF WITNESS

48B. TODAY'S DATE (MM,DD,YYYY)

PART XIII - REMARKS
51. REMARKS (Use this space for any additional information or statements that you would like to make concerning your application)

VA FORM 21P-534, XXX 2014

Page 9

PART XIII - REMARKS (Continued)
51. REMARKS (Continued) (Use this space for any additional information or 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-534, XXX 2013

Page 10

Form Approved
OMB Approved No. 0960-0062

SOCIAL SECURITY ADMINISTRATION

(DO NOT WRITE IN THIS SPACE)
VA DATE STAMP

APPLICATION FOR SURVIVORS BENEFITS

(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)

2. DATE OF DEATH

NOTE: If the veteran's Social Security No. is unknown, complete Items 4, 5, 6 and 7 about veteran.
3. SOCIAL SECURITY NO. OF VETERAN

4. DATE OF BIRTH

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

7. MAIDEN NAME OF MOTHER

6. NAME OF FATHER

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
PARENT
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.

CHILDREN: Show names of surviving children (including natural children, adopted children and stepchildren) or dependent grandchildren (including step
grandchildren) 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)

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

MARRIAGE

AGE

DEATH

(NAME)

OTHER (Specify)

(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 11

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 a
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.

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

Page 12