Form VA Form 21-4170 VA Form 21-4170 Statement of Marital Relationship

OMB Control No. 2900-0114
Respondent Burden: 25 Minutes
Expiration Date: XX/XX/XXXX
VA DATE STAMP
(DO NOT WRITE
IN THIS SPACE)

STATEMENT OF MARITAL RELATIONSHIP
INSTRUCTIONS: This form is to be completed by the veteran (if living) and the person who is claiming to be
the spouse or surviving spouse. Note: For the purposes of this form, the person who is claiming to be the spouse or
surviving spouse is referred to as "spouse or surviving spouse." Print all answers clearly. 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 17, "Remarks, " or attach a separate sheet, indicating the item number to which the
answers apply.
IMPORTANT INFORMATION: Submit any documents that show the veteran and the spouse or surviving spouse as husband and wife; for example, lease
agreements, joint bank statements, utility bills, tax returns, insurance forms, employment records, and any other documents showing marital status. Please be
advised that original documents will not be returned to you. We highly encourage you to submit certified copies instead.
SECTION I - INFORMATION ABOUT THE VETERAN AND THE SPOUSE OR SURVIVING SPOUSE

1. NAME OF VETERAN (First, Middle Initial, Last)

2. SOCIAL SECURITY NUMBER

3. VA FILE NUMBER

4. DATE OF BIRTH (MM/DD/YYYY)

6B. ALTERNATE TELEPHONE NUMBER
(Include Area Code)

5. VETERAN'S SERVICE NUMBER (If applicable) 6A. PREFERRED TELEPHONE NUMBER
(Include Area Code)

SECTION II - INFORMATION ABOUT THE SPOUSE OR SURVIVING SPOUSE

7. NAME OF SPOUSE OR SURVIVING SPOUSE (First, Middle Initial, Last)

8. SOCIAL SECURITY NUMBER OF SPOUSE ORSURVIVING SPOUSE

9. DATE OF BIRTH OF SPOUSE OR SURVIVING SPOUSE (MM/DD/YYYY)

10. COMPLETE ADDRESS OF VETERAN OR CLAIMANT (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)
No. &
Street
City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

SECTION III - INFORMATION ABOUT THE CLAIMED MARITAL RELATIONSHIP
11A. DATE YOU BEGAN LIVING AS HUSBAND
AND WIFE (MM/DD/YYYY)

11B. NAME(S) YOU WERE KNOWN BY BEFORE YOU BEGAN LIVING AS HUSBAND AND WIFE (First, Middle

Initial, Last)

11C. PLACE YOU BEGAN LIVING AS HUSBAND AND WIFE (Include number and street or rural route, P. O. Box, City, State,

ZIP Code and Country)
No. &
Street

City

Apt./Unit Number
State/Province

Country

ZIP Code/Postal Code

TO BE COMPLETED BY THE SPOUSE OR SURVIVING SPOUSE:
11D. AFTER YOU BEGAN LIVING WITH THE VETERAN, DID YOU USE HIS/HER LAST NAME?

ALWAYS

11E. WHAT DID YOU AGREE YOUR RELATIONSHIP WOULD BE AT THE TIME YOU BEGAN LIVING TOGETHER?

VA FORM
XXX XXXX

21-4170

SUPERSEDES VA FORM 21-4170-1, SEP 2014,
WHICH WILL NOT BE USED.

SOMETIMES

NEVER

VETERAN'S SOCIAL SECURITY NO.
11F. HAVE (HAD) YOU LIVED TOGETHER CONTINUOUSLY FROM THAT TIME UNTIL THIS DATE (OR THE VETERAN'S DEATH)?
YES

(If "Yes," skip to Item 13)( If "No," complete Item 12)

NO

12. LIST ALL PERIODS OF SEPARATION
BEGINNING DATE

ENDING DATE

(MM/DD/YYYY)

REASON FOR SEPARATION

(MM/DD/YYYY)

13. LIST ALL PERIODS OF TIME AND PLACES WHERE YOU LIVED AS HUSBAND AND WIFE
BEGINNING DATE

(MM/DD/YYYY)

ENDING DATE

ADDRESS (Street address, City, and State)

(MM/DD/YYYY)

SECTION IV - INFORMATION ABOUT YOUR CHILDREN

IMPORTANT INFORMATION: Send a certified copy of the public record of birth for each child listed in Item 14B.

14A. HAVE YOU HAD CHILDREN TOGETHER?
YES

(If "Yes," complete Item 14B) (If "No," skip to Item 15A)
14B. FULL NAME OF CHILD (First, Middle Initial, Last)

NO

14C. PLACE OF BIRTH (City/State or Country)

SECTION V - INFORMATION ABOUT YOUR MARITAL HISTORY

INSTRUCTIONS: Furnish complete information about all marriages of the veteran and spouse or surviving spouse. If you need additional space,
please attach a separate sheet of paper providing the requested information about the marriages.
IMPORTANT INFORMATION: Attach a copy of divorce decrees.
15A. HAS (HAD) THE VETERAN EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?
YES

NO

15B. DATE OF
MARRIAGE

(MM/DD/
YYYY)

(If "Yes," complete Items 15B through 15G) (If "No," skip to Item 16A)
15C. PLACE

(City/State or country)

15D. TO WHOM MARRIED

(First, Middle Initial, Last)

15E. DATE
MARRIAGE
ENDED

(MM/DD/
YYYY)

16A. HAS THE SPOUSE OR SURVIVING SPOUSE EVER LIVED WITH ANOTHER PERSON AS HUSBAND AND WIFE?
YES

NO

(If "Yes," complete Item 16B through 16G) (If "No," skip to Item 17)

VA FORM 21-4170, XXX XXXX

15F. PLACE

(City/State or country)

15G. HOW
MARRIAGE ENDED

(Death,
divorce, etc.)

VETERAN'S SOCIAL SECURITY NO.

16B. DATE OF
MARRIAGE

(MM/DD/
YYYY)

16C. PLACE

(City/State or country)

16D. TO WHOM MARRIED

(First, Middle Initial, Last)

16E. DATE
MARRIAGE
ENDED

(MM/DD/
YYYY)

16F. PLACE

(City/State or country)

16G. HOW
MARRIAGE ENDED

(Death,
divorce, etc.)

17. REMARKS (If any)

SECTION VI - CERTIFICATION, SIGNATURE(S), AND WITNESSES

I CERTIFY THAT the statements in this document are true and correct to the best of my knowledge and belief.
18A. SIGNATURE OF VETERAN (Sign in ink)

18B. DATE SIGNED

19A. SIGNATURE OF CLAIMED SPOUSE OR SURVIVING SPOUSE (Sign in ink)

19B. DATE SIGNED

SECTION VII-WITNESSES TO SIGNATURES IF MADE BY "X" MARK
NOTE: Signature by mark must be witnessed by two persons to whom the veteran or the claimed spouse or surviving spouse is personally known and the signatures and
addresses of the witnesses must be entered below.
20A. SIGNATURE OF WITNESS (Sign in ink)

20B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

21A. SIGNATURE OF WITNESS (Sign in ink)

21B. ADDRESS OF WITNESS (Number and street, City, State and ZIP Code)

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.
PRIVACY ACT INFORMATION: 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 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). 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 eligibility for additional benefits as a spouse of a veteran or eligibility for pension or dependency
and indemnity compensation as the surviving spouse of a veteran (38 U.S.C. 101, 103, and 1102). We estimate that you will need an average of 25 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 21-4170, XXX XXXX