Form 21P-0537 Marital Status Questionnaire

You are receiving Dependency and Indemnity Compensation (DIC) as the surviving spouse of a veteran
who died in service or from service-connected conditions. Generally, a surviving spouse's entitlement to
DIC ends with remarriage. If a surviving spouse remarries, entitlement may continue provided the
marriage began after age 57 or has been terminated. You are responsible for reporting any change in your
marital status.
We need to verify your marital status. Please answer the questions below.
If you do not return this letter with your answers to VA within 60 days of the date shown above, we may
propose to terminate your DIC benefits. After answering the questions below, please return this letter in
the enclosed envelope. Be sure to place it in the 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 a representative of
your choice.
If You Have Questions or Need Assistance
If you have any questions, you may contact us by telephone, e-mail, or letter.
If you:

Telephone
Use the Internet
Write

Here is what to do:

Call us at 1-877-294-6380. If you use a Telecommunications Device
for the Deaf (TDD), the number is 711.
Send electronic federal inquiries through the Internet at
https://iris.va.gov.
Put your full name and VA file number on the letter. Please send all
correspondence to the address at the top of this letter.

Sincerely yours,

Regional Office Director
Enclosure

(See Reverse)

VA FORM
XXXX

21P-0537

OMB Approved No. 2900-0495
Respondent Burden: 5 Minutes
Expiration Date: XXXXX

MARITAL STATUS QUESTIONNAIRE
PRIVACY ACT INFORMATION: Payment of survivor's benefits cannot be made unless the information requested is furnished as required by existing law
(38 U.S.C. 101(3)). The responses you submit are considered confidential, (38 U.S.C. 5701). They may be disclosed outside the Department of Veterans Affairs
only if the disclosure is authorized by the Privacy Act, including the routine uses identified in the system of records, 58VA21/22/28, VA Compensation, Pension,
Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. The requested information is considered relevant and
necessary to determine maximum benefits under the law. Information submitted is subject to verification through computer matching programs with other agencies.
You are required to provide the Social Security number requested under 38 U.S.C. 5101(c)(1). VA may disclose Social Security numbers as authorized under the
Privacy Act, and, specifically may disclose them for purposes stated above.
RESPONDENT BURDEN: We need this information to determine your continued eligibility for DIC benefits. Title 38, U.S.C., allows us to ask for this
information. We estimate that you will need an average of 5 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
1-877-294-6380 to get information on where to send comments or suggestions.

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/.

1A. HAVE YOU REMARRIED SINCE THE DEATH OF THE VETERAN?
YES

NO

1B. DATE OF MARRIAGE

(If "Yes," please provide the date in Item 1B, the name of your spouse in Item 1C,
and your spouse's date of birth in Item 1D)

1C. NAME OF SPOUSE

1E. IS YOUR SPOUSE A VETERAN?

1D. SPOUSE DATE OF BIRTH

1F. IF "YES," PROVIDE YOU NEW SPOUSE'S VA 1G. WHAT WAS YOUR AGE AT THE TIME OF
FILE NUMBER OR SOCIAL SECURITY NUMBER YOUR MARRIAGE?

YES
NO
2A. HAS YOUR REMARRIAGE BEEN TERMINATED?
YES

NO

(If "Yes," please provide the date in Item 2B and the reason for termination (i.e., death, divorce) in Item 2C)

2B. DATE OF TERMINATION

2C. REASON FOR TERMINATION

3A. DAYTIME TELEPHONE (Include Area Code)

3B. EVENING TELEPHONE NUMBER (Include Area Code)

4. E-MAIL ADDRESS
5A. SIGNATURE
VA FORM
XXXX

21P-0537

5B. DATE SIGNED